ART THERAPY TREATMENT WITH INCARCERATED WOMEN

by

BONNIE J. ERICKSON
B.F.A. Utah State University, 1975
M.S. Stetson University, 2000

A dissertation submitted in partial fulfillment of the requirements

for the degree of Doctor of Philosophy
in the Department of Child, Family, and Community Sciences
in the College of Education
at the University of Central Florida
Orlando, Florida

Fall Term
2008

Major Professor: Mark E. Young

2008 Bonnie J. Erickson

ii

ABSTRACT
This study examined the effectiveness of art therapy in decreasing symptoms of trauma
and psychological distress in women who were incarcerated in county jails in the Southeastern
United States. In order to protect the integrity of the study, control subjects were in different
dormitories from the treatment subjects. While the dormitories were randomly assigned to
treatment or control, the subjects were not. The dependent measures were paper and pencil tests,
the Outcome Questionnaire (OQ-45.2) and the Trauma Symptom Inventory (TSI) given at
pretest and posttest. A demographic questionnaire was completed in the first session to better
characterize the participants. In addition, a post study evaluation with open ended questions was
completed at the end of the study that allowed participants to share their feelings about the
treatment experience. Additional qualitative information was obtained through observation data
collected by the investigator who served as the provider of treatment.
Art therapy group participants attended six sessions of art therapy over a three week
period which was administered using six standard art projects. Like treatment subjects, control
participants had access to the treatment available in the jail to all inmates, and were offered art
therapy treatment after final data were obtained.
Though the statistical data gathered in this study did not provide empirical evidence that
the group art therapy treatment was effective in reducing symptomatology, the qualitative
responses indicated that the treatment was rated very positively by the participants. No
statistically significant changes were found in overall scores, however, some significance was
found on some individual treatment scales. Scores measuring psychological distress and trauma
symptoms generally decreased over time for all study participants, however, treatment

iii

participant scores improved at a greater rate. The study was limited due to small sample size
(N=26). Nearly half of the original participants were lost to attrition associated with
administrative actions in the county jail system. The measurement instruments used were not
specifically adapted to incarcerated individuals and may not have provided adequate
measurement for this population.
Responses from the participants were overwhelmingly positive. Inmates responses to the
post study evaluation indicated that they had enjoyed the experience and would recommend the
group to others. More than 75% stated that they felt that the treatment had helped them deal with
difficult experiences in their past. The most frequent suggestion for the future was that the
groups needed to be continued, and should be longer and more frequent.

iv

ACKNOWLEDGMENTS
Anything worth doing requires sacrifice, not only for the individual themselves but for
those around them who share their life. I am grateful to my husband and children who have dealt
with my challenges along with me, and offered constant encouragement, love, and support. Dr.
Mark Young who served as the chair of my dissertation committee provided encouragement, and
guidance and taught me about tenacity and the importance of approaching this project one step at
a time. He is a great teacher, editor, mentor and friend. I acknowledge and appreciate the
friendship and support of the members of my cohort, Gulnora Hundley, Linda Robertson, Nicole
Vaccaro, and Tyson Kuch. I also appreciate Dr. Peggy Moch for her help with statistical
procedures. and her friendship and support throughout this process. This project would not have
been possible without the cooperation of the administrators of county jails who made it possible
for me to provide art therapy treatment inside correctional facilities, and especially, the female
inmates who participated in this project.

TABLE OF CONTENTS
LIST OF FIGURES .............................................................................................................x
LIST OF TABLES............................................................................................................. xi
LIST OF ABBREVIATIONS........................................................................................... xii
CHAPTER ONE: INTRODUCTION..................................................................................1
Trauma ............................................................................................................................ 4
Theoretical Background.................................................................................................. 5
Art Therapy..................................................................................................................... 6
Purpose of the Study ....................................................................................................... 7
Research Question .......................................................................................................... 8
Research Design ............................................................................................................. 8
Recruitment and Enrollment Procedures .....................................................................9
Administration ...........................................................................................................10
Materials ....................................................................................................................10
Measures ....................................................................................................................... 10
Assumptions.................................................................................................................. 12
Limitations .................................................................................................................... 13
Conclusion .................................................................................................................... 13
CHAPTER TWO: LITERATURE REVIEW....................................................................15
Special Concerns for Female Inmates .......................................................................... 15
Causes for Recidivism .................................................................................................. 17
Domestic Abuse and Criminality.................................................................................. 18
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Mental Health of Female Inmates................................................................................. 20

Mental Health Services in Correctional Institutions..................................................... 21
Counseling Inside a Correctional Facility .................................................................... 23
Expressive Arts ............................................................................................................. 25
Advantages of Expressive Art Therapies...................................................................27
Effectiveness in Correctional Facilities .....................................................................29
Expressive Writing.....................................................................................................30
Art Therapy................................................................................................................... 31
Art Therapy for Trauma Treatment ...........................................................................33
Art Therapy within Correctional Facilities ................................................................34
Arts Therapy in Groups .............................................................................................37
CHAPTER THREE: METHODOLOGY ..........................................................................39
Research Question ........................................................................................................ 39
Research Design and Limitations ................................................................................. 39
Participants.................................................................................................................... 40
Approval Procedures..................................................................................................... 40
Recruitment and Enrollment Procedures ...................................................................... 41
Treatment Procedures ................................................................................................... 42
Instruments.................................................................................................................... 46
Trauma Symptoms Inventory (TSI)...........................................................................46
Outcome Questionnaire (OQ45.2) .............................................................................47
Demographic and Post-test Questionnaires ...............................................................47

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Data Collection Procedures .......................................................................................... 48

Data Analysis................................................................................................................ 48
Summary....................................................................................................................... 49
CHAPTER FOUR: FINDINGS.........................................................................................50
Study Participation and Data Collection....................................................................... 50
Demographic Summary ................................................................................................ 52
Statistical Analyses ....................................................................................................... 54
Statistical Analysis: MANOVA.................................................................................65
Qualitative Results........................................................................................................ 69
Summary of Findings.................................................................................................... 70
CHAPTER FIVE: CONCLUSIONS .................................................................................71
Limitations of the Study ............................................................................................... 72
Instruments.................................................................................................................... 74
Review of Findings....................................................................................................... 77
Treatment Procedures ................................................................................................... 80
Qualitative Results........................................................................................................ 91
Recommendations for Future Research and Implications ............................................ 93
APPENDIX A: IRB APPROVAL .....................................................................................97
APPENDIX B: RECRUITMENT FLYER........................................................................99
APPENDIX C: INFORMED CONSENT........................................................................101
APPENDIX D: ART THERAPY TREATMENT EXERCISES.....................................105
APPENDIX E: DEMOGRAPHIC QUESTIONNAIRE..................................................114

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APPENDIX F: POST STUDY EVALUATION .............................................................118

REFERENCES ................................................................................................................120

ix

LIST OF FIGURES
Figure 1 Attrition Flow Chart ....................................................................................................... 52
Figure 2 Differences Between OQ-45.2 Pretest and Posttest Scores............................................ 67
Figure 3 Differences Between TSI Pretest and Posttest Scores.................................................... 68
Figure 4 Happily Ever After. ........................................................................................................ 82
Figure 5. Masks A......................................................................................................................... 83
Figure 6. Masks B. ........................................................................................................................ 84
Figure 7. The Child Within........................................................................................................... 85
Figure 8. Monsters A. ................................................................................................................... 86
Figure 9. Monsters B..................................................................................................................... 87
Figure 10. My Most Upsetting Experience A............................................................................... 88
Figure 11. My Most Upsetting Experience B. .............................................................................. 89
Figure 12. Lost and Found. ........................................................................................................... 90

LIST OF TABLES
Table 1. OQ-45.2 Scores for Art Therapy and Control Groups at Pretest.................................... 55
Table 2. TSI Scores for Art Therapy and Control Groups at Pretest............................................ 57
Table 3. Art Therapy Treatment Comparison for Pretest and Posttest OQ-45.2 Scores .............. 59
Table 4. Control Group Comparison of Pretest and Posttest OQ-45.2 Scores ............................. 60
Table 5. Art Therapy Treatment Group Comparison of Pretest and Posttest TSI Scores ............ 61
Table 6. Control Group Comparison of Pretest and Posttest TSI Scores ..................................... 62
Table 7. OQ-45.2 Scores for Art Therapy and Control Groups at Posttest. ................................. 63
Table 8. TSI Scores for Art Therapy and Control Groups at Posttest .......................................... 64

xi

LIST OF ABBREVIATIONS
IRB

Institutional Review Board

OQ45.2

Outcome Questionnaire

PTSD

Post Traumatic Stress Disorder

SSPS

Statistical Package for Social Sciences

TSI

Trauma Symptoms Inventory

xii

CHAPTER ONE: INTRODUCTION

The number of incarcerated women in the United States are increasing at an alarming rate. A
closer look reveals underlying issues influencing this trend. Approximately three quarters of female
inmates in local jails in the United States meet the criteria for a mental health diagnosis and co-occurring
substance abuse diagnosis (James & Glaze, 2006). In addition the majority of incarcerated women have
a history of trauma including sexual, emotional and physical abuse as children and adults and have a cooccurring mental health diagnoses at the time of incarceration (Mageehon, 2003). As many as two thirds
of women newly admitted to jails suffer sufficient psychological distress requiring mental health
services (Singer, Bussey, Song & Lunghofer, 1995). This suggests a need to review current treatment
issues and the potential need for development of alternative, efficient, effective options for this
population.
Incarcerated women report a high incidence of traumatic experiences prior to their arrests. Singer
et al. (1995) found that 81% of the female inmates interviewed reported having been sexually victimized
at some time in their lives and three fourths reported having been threatened with physical violence over
the previous year. In addition, nearly half of female inmates reported that they had experienced trauma
within the year before their incarceration (Wellisch, Anglin, Douglas, & Pendergast 1993). These
included rape, assault, domestic violence, and being a witness to violence (Pomeroy, Kiam, & Abel,
1998). According to Wellisch et al. (1993) nearly half of the incarcerated women surveyed had
experienced physical abuse, frequently at the hands of their husbands or boyfriends, while 36% had been
subjected to sexual abuse. Many experienced life disrupting traumatic experiences at an early age that
led to discontinued educational pursuits, substance abuse, and deviant behaviors, that in turn,
contributed to their subsequent incarceration (Wellisch et al.).

Because of the overwhelming occurrence of mental health disorders, trauma and substance abuse
issues in female correctional facilities, mental health staff are often unable to provide adequate treatment
for inmates. (Singer et al., 1995; Pomeroy et al., 1998). Treatment modalities for trauma that are
currently used successfully are impractical in an incarcerated setting. Most of these treatments require
one-on-one counseling, intense group work, and in some cases, specialized training. While cognitive
behavioral therapy, exposure therapy, and others are considered to be effective treatments for trauma,
inmates are seldom able to receive individual treatment considering the ratio of counselors to inmates
(Pomeroy et al. (1998). Much work needs to be done to find alternative treatments that can be delivered
to this underserved population (Ferszt, Hayes, DeFedele, & Horn, 2004).
Art therapy techniques have also been found to be effective in relieving a wide array of
physical and psychological symptoms experienced by children and adolescents. In studies with
children, Gross & Haynes (1998) found that art therapy can be used to tap the bodys relaxation
response which, in turn, reduces anxiety, strengthens client-therapist relationships, increases
memory retrieval, helps clients to organize narratives and encourages more detailed disclosure
than in a verbal interview (Gross & Haynes, 1998; Malchiodi, 2001). Art therapy has been used
to help children cope with loss (Finn & Pearson 2003), divorce and family upheaval, physical
illness, loneliness, trauma, (Hanney & Kozlowska, 2002) autism, developmental issues, learning
disabilities, and abuse. Adolescents have also been effectively treated with art therapy for a
variety of symptoms including the traumas of September 11 (Pressman, 2005), physical illness,
substance abuse, trauma, sexual and physical abuse (Gladding, 2005).
Art therapy has been used successfully with adults in family therapy, individual and
group therapy addressing a wide array of problems (Gladding, 2005; Kwiatowski, 2001;

Malchiodi, 2003; Rubin, 2001). Collie, Backos, Malchiodi and Spiegel (2006) advocated
utilizing art therapy with veterans who have been traumatized by war. The use of art therapy
allows each person to address his or her own issues while in the supportive confines of a group
(Waller, 2003).
Several facets of prison life and culture render art therapy a good treatment for inmates. For
example, verbal expression of extreme emotions while incarcerated sometimes leads to negative
consequences. However, expression through art facilitates intense expression in acceptable and
appropriate ways (Gussak, 2006). Art therapy can be effectively administered in group settings making
it possible to provide treatment for a broader population with limited resources. Art therapy treatment
work provides a tangible record of psychological processing which can be valuable as treatment
progresses (Ferszt, Hayes, DeFedele, & Horn, (2004). The positive anecdotal effects of art therapy use
with incarcerated individuals have been reported by many clinicians (e.g. Cronin, 1994; Eisdell,
2005;Wilson, 2000).
This study offers an opportunity to address trauma related outcomes while providing
needed treatment in order to reduce symptomology, alleviate individual distress, and increase the
likelihood of functional life changes for participants. More effective treatment options and
methodologies need to be developed and made available in order to raise client coping skills and
facilitate reduction in recidivism (Pomeroy et al. 1998). Art therapy techniques used in group
settings provide a practical, efficient, economic, and effective way to provide treatment to
incarcerated individuals.

Trauma
In order to better understand trauma, we must first understand how it is defined. Trauma
is defined by the American Psychiatric Association as an event or events that involved actual or
threatened death or serious injury, or a threat to the physical integrity of self or others (DSMIV-TR, 2000, p.424). Psychological trauma occurs when an individual experiences some event
that overwhelms their ability to cope and they fear death, annihilation, mutilation or psychoses.
The circumstances of the event commonly include abuse of power, betrayal of trust, entrapment,
helplessness, pain, confusion and loss. The definition of a trauma is fairly broad, ranging from
powerful one-time incidents like natural disasters, or accidents, to long-term repetitive
experiences such as combat, battering or child sexual abuse (Giller, 1999).
Most recipients of mental health treatment have experienced trauma in some form. In
fact, two prevalent psychological conditions described in the Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text Revision (DSM IV TR, 2000), Posttraumatic Stress
Disorder (PTSD) and Acute Stress Disorder (ASD), identify trauma as an etiological element in
the diagnostic criteria (DSM IV TR, 2000). Trauma is found at the root of many mental health
disorders including anxiety disorders, personality disorders, substance related disorders and
dissociative disorders, as well as eating, sleeping, sexual, and behavioral disorders (Giller, 1999).
Trauma is believed to be both a psychological and a physiological experience. PTSD has both
psychological and physiological symptoms. Because the core of traumatic experience is
physiological, the expression and processing of sensory memories of the traumatic event are
essential to successful intervention and resolution (Rothchild, 2000).

Theoretical Background
Expression of emotions related to trauma is crucial to client recovery (Frattaroli, 2006;
Malchiodi, 2005). According to Young & Bemak (1996) individuals who have difficulty
expressing themselves verbally are more likely to benefit from expressive treatments. Expressive
arts offer a unique, effective avenue for expression and catharsis (Gladding, 2005; Malchiodi,
2003). Art therapy and expressive writing have both been found to be effective in relieving
traumatic symptoms and improving emotional functioning (Gladding, 2005, Malchiodi, 2005;
Pennebaker, 1990). Gussak (2005) suggested that the use of expressive arts therapies can bypass
the resistance that is often present when working with inmate populations, enabling them to
address and express experiences that are difficult to verbalize.
One of the most important contributions to the use of expressive modalities is evident in
Pennebakers research based on his theory of psychosomatic inhibition. This theory assumes that
individuals who are reluctant to express thoughts and feelings related to traumatic experiences
have increased stress which leads to physical illness and impaired psychological functioning
(Pennebaker, 1990). He posits that psychological pain is often exhibited in the form of physical
pain, leading the individual to seek help, and that this behavior is linked to difficulty in
disclosing upsetting memories. Traumatic memories are thought to be stored in a unique way,
and are not as readily accessible to verbal disclosure. Pennebaker (1990) stated that they are
more readily accessed through writing or visual therapy techniques. Pennebakers work with
trauma identified physiological benefits when participants expressed their feelings about
traumatic experiences and related emotions. He concluded that the benefits derived were threefold. First, when an individual is able to express strong emotions related to trauma it leads to an

awareness of deeper unconscious emotions. Second, expressing emotions helps the individual
realize that he has some responsibility for his emotional experiences and can do something to
resolve them. And third, through expression, the individual gains insight and understanding into
his experiences and is able to begin to resolve them (Pennebaker).
Art Therapy
Many therapists concur that because memories of trauma are stored in a visual form, it is
a natural and effective practice to encourage visual representation of those memories prior to
verbal disclosure (Rubin, 2001; Gladding, 2005). Throughout history creative expression in
many forms has been employed to process life experiences (Malchiodi, 2005). From the earliest
attempts to help individuals deal with past experiences, imagery and verbal expression have been
used (Malchiodi, 1998). Specific drawing tasks can be effective in tapping sensory memories and
generating narratives. There are two kinds of memories implicit and explicit (Rothchild, 2000).
Explicit memories consist of facts, concepts and ideas. Implicit memories are sensory, emotional
ideas. Rothchild posited that art expression may help to bridge between implicit and explicit
memories by facilitating the creation of a narrative through which a person can explore
memories. Developing a sense of why they are upsetting, which, in turn, helps the client to think
and feel concurrently while examining difficult experiences.
Because the field of art therapy is a relatively new field, possibilities for its use are
constantly expanding. It is seen as a modality to help individuals to verbalize their thoughts,
feelings, beliefs, problems and world view (Malchiodi, 2003, p.2). It is considered an adjunct to
psychotherapy that can be used to enable verbal expression through making visual images. In
addition, the process of making images itself, is viewed as the therapy; the creative process

involved in creating art is life enhancing and therapeutic. Most therapists who use art in practice
agree with both of these perspectives and that its use does assist people in expressing things that
may be difficult to verbalize. It works in a way that verbal interviews and interventions can not
(Malchiodi, 2003). Art therapy draws upon the creative process within every individual to
promote growth, self-expression, emotional reparation, conflict resolution and transformation
(Malchiodi, 1998).
Purpose of the Study
The purpose of this study was to evaluate the effectiveness of art therapy interventions
when treating female inmates experiencing trauma related issues to determine if symptoms were
reduced and psychological outcomes improved through its use. This study compared expressive
therapy methods with existing treatment offered to female inmates. This study contributes to the
body of knowledge about art therapy and treatment options in an incarcerated setting.
Women in jail report a high incidence of trauma and mental health issues. Because, those
who are incarcerated have limited access to mental health treatment, traditional therapies such as
cognitive behavioral therapy, EMDR, and exposure therapy which require intense and individual
counseling attention are not practical in a prison setting. Counseling personnel in a county
correctional facility have a large client load. Individualized, consistent treatment is difficult to
provide due to the extreme need and the transient nature of county jail populations. Most often,
counseling services are limited to mental health status assessments, psychiatric referrals, and
individual counseling to limited clients, usually on a monthly basis.
The art therapy treatment used in this study can be applied in group settings allowing
more inmates to receive treatment than individual modalities afford. Art therapy use for brief

group treatments has the potential to provide additional effective treatment options for
incarcerated individuals. Positive outcomes with the use of art therapy with female inmates who
have experienced high instances of trauma may indicate that individuals who have experienced
less severe trauma in other treatment settings would also benefit from its use.
Research Question
The research question is as follows: Are expressive arts treatments effective in decreasing
symptoms of trauma and psychological distress in incarcerated women?
Research Design
A study was conducted with incarcerated females in two county corrections facilities in
the Southeastern United States. Participants attended six sessions over a three-week period in the
art therapy group, and the control group received only the treatment available through the
correction facility. Pre-test and post-test measures were taken at the beginning and end of the
three-week treatment period. Because of the living arrangement for inmates who live in separate
dorms called pods it was not practical or desirable to randomly assign subjects to treatment
groups. Due to the structure of the jail, and the interaction of inmates with each other in the
dorm, in order to protect the integrity of the study, the volunteers were assigned to groups
according to the dorm where they were housed.
Approval procedures included an application to the Director of Corrections, and
programs staff at the John E. Polk Correctional Facility, Seminole County, Florida, and the Lake
County Florida Correctional Facility. The study complied with all regulations set forth by the
American Corrections Association and the National Commission on Correctional Health Care.
IRB applications were submitted and approved through the University of Central Florida.
8

Recruitment and Enrollment Procedures

A flyer was displayed in pods where female inmates are housed describing the study
asking for volunteers for the study and inviting them to attend an introductory session where they
would learn about the study, trauma, and related symptomology. They were informed that
participation was voluntary and that they had the option to drop out at any time without negative
consequences. They were informed that their participation would have no affect upon their
standing in the jail. They were informed of confidentiality issues regarding the study, and were
informed that they would receive no tangible rewards such as money or goods for participation
according to corrections regulations. Individual informed consent agreement forms were
provided for sign-up and were collected by the Programs Director.
Participants were assigned a confidential identification number to identify treatment work
and research instruments. Numbers coincided with a master list of participants kept by the
primary investigator in a password protected file on a laptop computer at another location, and
were used only to record pre-test and post-test scores appropriately. Participants were asked to
refrain from adding identifying information to their drawings and any inadvertent use of names
were blacked out before the work was viewed.
Treatment groups met twice each week for three weeks. Individuals in the control group
participated in the pretest and post test at the same time as treatment groups, and were given the
opportunity to receive art therapy treatment after post-tests were administered. Digital photos of
client artwork were made for reference and further research. All original treatment work was
returned to the participants.

Administration
In order to maximize the quality of care, the treatment was administered by the primary
investigator who has experience working with incarcerated clients and has provided art therapy
in an incarcerated setting. Approval to enter the correctional facility required an extensive
background check and application process as well as security training provided by the facility.
Specific intervention protocols were used for each session. Groups were held in a classroom
inside the facility. Each session consisted of a brief introductory discussion to clarify concepts
and describe treatment tasks, then participants were given time to complete treatment work. Each
session concluded with a brief group discussion where each individual shared their drawing and
their feelings and insights about the experience.
Materials
Materials required for the interventions were provided by the primary investigator. All
facility regulations concerning appropriate materials for inmate use were observed. Materials
included drawing paper, water-based markers, crayons and pencils.
Measures
Data was obtained through pre-test and post-test measures using four instruments. The
Trauma Symptoms Inventory (TSI) (Briere, 1995) and the Outcome Questionnaire (OQ-45.2)
(Lambert et al. (2004) both in wide use (Merker, n.d.; Fernandez, n.d.), were selected as
measures to evaluate changes in psychological outcomes scores. A demographic questionnaire
developed for this study was used to gather information about the participants which included
age, marital status, education level, number of children and their custody status, incarceration
history, substance use history, and mental and medical health history. At the conclusion of the
10

study, participants completed a short questionnaire with open-ended questions to evaluate their
experience.
The Trauma Symptoms Inventory (TSI) (Briere, 1995) was designed to evaluate acute
and chronic traumatic symptomology in adults. The measure consists of 100 items describing
trauma-related symptoms that are to be rated on a 4-point scale of frequency of occurrence over
the preceding six months. The test is written on a 5th to 7th grade reading level and requires
approximately 20 minutes for completion. Scores reflect ten symptom domains: Anxious Arousal
(AA), Depression (D), Anger/Irritability (AI), Intrusive Experiences (IE), Defensive Avoidance
(DA), Dissociation (DIS), Sexual Concerns (SC), Dysfunctional Sexual Behavior (DSB),
Impaired Self-reference (ISR), and Tension Reduction Behavior (TRB).
The TSI was administered by the test developers to a random adult sample from the
general population (N=828) and with Navy recruits (N=3,659). Separate norms indicate that the
TSI is appropriate for adults with combinations of age and gender. Built-in validity scales are:
Atypical Response (ATR), Response Level (RL), and Inconsistent Response (INC). The average
alpha coefficient for all clinical scales is .85 (Briere, 1998). The TSI showed reasonable
concurrent validity when compared with similar scales, and data indicates overall psychometric
soundness.
The OQ-45.2 (Outcome Questionnaire) developed by Lambert & Burlingame (1998) is a
45-item self-report questionnaire designed as a brief screening and outcome assessment scale
that measures subjective distress as well as the effects on how they function in the world.
(Lambert, et al. 1998). The instrument can be completed in approximately 10-15 minutes and is
written at a sixth grade reading level (Hanson, 2007; Merker, 2007). The questions are rated on a

11

5-point Likert scale with responses of never to almost always. In addition to the total score, the
OQ-45.2 measures how a person is feeling, getting along with others, and how they are
functioning in important life tasks, with three sub-scores: symptom distress (SD), interpersonal
relationships (IR), and social role and occupational functioning (SR). This instrument is sensitive
to change and was designed for repeated administration, and has been found to be broadly
applicable across ages, diagnoses, treatment modalities and clinician orientations. Both Hanson
(2007) & Merker (2007) indicated that one strength of this instrument is its ability to identify
potential treatment failure. Pfeiffer (n.d.) states that the reliability of .93 indicates that the OQ45.2 is psychometrically sound, and that the Reliable Change Index (RCI) facilitates measures of
change during the course of treatment.
Assumptions
The study was conducted in two county correctional facilities. The assumption was made
that the populations were similar and that responses to the test instruments would be constant.
Study participants were assigned to groups according to their living arrangements, it was
assumed that the groups assigned to the treatment group and the control group had experienced
similar trauma and would respond about the same to the measurement instruments. The
instruments used were self-response, it was assumed that participants would respond honestly.
One assumption made in this study was that a population who has experienced more severe
trauma may produce more dramatic differences in psychological outcome scores. It is also
assumed that a more intense treatment consisting of several sessions over a three-week period
would provide enough time and intensity for the treatments to be effective and that the
psychological outcome scores would indicate these results.

12

Limitations
Conducting this study in an incarcerated setting provides a group of individuals who have
experienced extreme trauma therefore results may not transfer to a non-incarcerated population.
In county correctional facilities the population is transient, attrition occurs for a variety of
reasons including the early release of inmates, transfers, and other changes in jail housing.
Establishing a trusting therapeutic relationship can be challenging with incarcerated participants.
Even though they were informed that responses would not be shared with corrections staff and
would have no effect on the disposition of their case, participants may not have responded
honestly, in an effort to appear healthier than they are. Because of differing perspective on
dealing with inmates, cooperation with correctional staff can be challenging and effects the
administration of the study.
Conclusion
The women who populate the county jail system have experienced extensive trauma,
addiction and related issues and are in need of quality mental health care. They often find
themselves in a cycle of incarceration and dysfunction with little accessibility to treatment in the
community or as an inmate. This study explores art therapy as an alternative treatment option
that could be beneficial in alleviating distressing symptomology to clients while offering
reasonable options for treatment in correctional facilities where treatment is currently difficult to
obtain.
A discussion of this study follows. Chapter One addresses the organization and purpose
for the study. It elaborates upon the theoretical foundations of art therapy. Chapter Two reviews
literature relevant to working with incarcerated clients and explores the unique characteristics of

13

this population. A review of current research utilizing art therapy applications in correctional
settings is also included. Chapter Three describes the methodology used to conduct the study and
a description of treatment and data collection procedures. Data analysis and research findings are
discussed in Chapter Four. Chapter Five discusses implications of the study and suggestions for
further research.

14

CHAPTER TWO: LITERATURE REVIEW

Women are the fastest growing group entering the criminal justice system. Between the
years of 1980 and 1995, female arrest rates grew at a rate of 200% (Pomeroy, Kiam, & Abel,
1998). They have tripled since; leaving about 1% of all adult females in the United States
imprisoned (Covington, 2007). This rapid growth is complicated by the prevalence of recidivism,
as nearly three quarters of inmates have been arrested two or three times previously (Alemagno,
2001). The explosion of this population has even wider social implications when its
intergenerational effects are considered. Evidence has shown that families with incarcerated
parents often lead to incarcerated children (Norton-Hawk, 2001). Even with a population of
approximately one million, women represent only 11% of the incarcerated population (Bradley
& Davino, 2007; Covington, 2007). Consequently, they are now frequently housed in facilities
and enrolled in programs that were originally designed for men (Henriques, 2002; Radosh,
2002). The unique issues affecting women arrestees, and the growth of their population, reveal
the need for a change in current correctional practices.
Special Concerns for Female Inmates
In one of the most important demographic studies of incarcerated women, Wellisch et al.
(1993) found that most female inmates had one to three children and became mothers at or prior
to the age of eighteen. Approximately 4% were pregnant when arrested and more than 75% of all
incarcerated women were mothers with children under eighteen. The continuous involvement of
mothers with incarceration, substance abuse, and unaddressed psychological problems has costly

15

implications for society in general and specifically for the development of children (Henriques,
2002).
Women detainees express overwhelming concern about the welfare of their children
while they are in prison and their ability to care for them when they are released (Radosh, 2002).
More than half lived with their children before entering jail and will return to live with them
when they are released. In the meantime, children are left to be cared for, in the majority of
cases, by the offenders mother or grandmother (Wellisch et al. 1993). Many female inmates
have lost parental rights to some or all of their children. However, others were involved in
ongoing child abuse or custody investigations to determine the placement of their children while
incarcerated and after release. Due to their role as care-taker before coming to jail, women
continue to be concerned about their family responsibilities, whereas most male inmates trust
that these needs will be met by others (Grella, & Greenwell, 2007).
Female detainees are also more likely than their male counterparts to suffer from health
concerns while incarcerated. They are more likely to suffer from chronic physical health
problems and less likely to receive adequate medical care (Grella & Greenwell, 2007).
Compared to other women, inmates demonstrate higher instances of many medical conditions
including: toxemia, anemia, hypertension, diabetes, obesity and a higher instance of infectious
diseases, sexually transmitted diseases, HIV/AIDS, hepatitis A, B, C, and tuberculosis
(Covington, 2007). Womens health needs are further complicated by additional reproductive
health care issues such as unplanned pregnancies and inconsistent use of birth control (Grella &
Greenwell, 2007). Despite the increased prevalence of these physical ailments, women are less
likely than men to seek health care services in jail due to fear of exposure or intimidation (Staton,

16

Leukefeld, & Logan, 2001). The lower health status of female inmates is related to high risk
behaviors such as alcohol and drug use, smoking, prostitution, and histories of trauma
(Covington, 2007). For many female inmates these behaviors constitute a cycle that will return
them to jail repeatedly.
Causes for Recidivism
Unlike men, women are primarily arrested for non-violent crimes with an economic
motive (Wellisch et al. 1993) such as drugs or drug-related offenses, prostitution, or fraud
(Covington, 2007; Radosh, 2002; Singer et al. 1995). Drug involvement is often related to their
relationships with men and their offenses are frequently tied to obtaining drugs. Women caught
in a cycle of drug use, crime, and incarceration find it difficult to escape faulty life patterns. In a
study conducted by Norton-Hawk (2001) women involved in prostitution claimed that they did
not enter prostitution to finance drug habits, however, they admitted that they eventually used
drugs regularly to make the job more tolerable. Drug use, in return, demands a large amount of
money that is difficult for them to obtain through any other means. As many as 95% of
prostitutes surveyed admitted that they were addicted to alcohol and illegal drugs (Norton-Hawk,
2001). Many incarcerated women have engaged in prostitution as a way to support drug use, and
continued to use drugs to enable them to endure prostitution. This perpetuates a cycle that is
difficult to escape. The cycle consists of repeated arrests and incarcerations with an eventual
release to face the same problems they had before incarceration or worse resulting in their return
to prostitution and other crimes (Radosh, 2002; Singer et al., 1995).
Much of the recidivism among women entering the jail system stems from a struggle to
find and maintain adequate employment due to a lack of education and vocational skills (Hall,

17

Baldwin, & Prendergast, 2001). In general, incarcerated women have limited employment skills,
poor work norms, and erratic work experience further complicated by practical and logistical
problems such as transportation, housing and child-care. Less than 20% felt they were qualified
to get the kind of job they would like (Grella & Greenwell , 2007). Radosh (2002) found that
most women detainees had experienced financial difficulties before incarceration and that only
about 40% were employed at the time of their arrest. Approximately 20% said they had been
unemployed for three years before being arrested (Radosh, 2002). In one possible explanation,
Mcgeehon (2003) concluded that some life-altering event had disrupted the education of many
female inmates during adolescence. Frequently, despite early positive educational experiences,
they failed to complete middle or high school. A study by Wellisch et al. (1993) revealed that
only about 15% of incarcerated women had completed four years of high school and 24% had
obtained a GED. According to Mcgeehon (2003), the events that had interrupted inmate
womens education included ongoing difficulties at home, repeated rapes, physical abuse, sexual
abuse, and early childbirth, resulting in disconnection from peers and teachers (Wellisch et al.
1993).
Domestic Abuse and Criminality
Womens incarceration stems from an array of domestic problems that affect women as a
group and permeates many facets of American culture. Prior to incarceration, many of these
women lived in poverty with parents who abused alcohol and drugs. A history of abuse is also
believed to increase the likelihood of contact with the justice system and perpetuates a cycle of
intergenerational violence (Henriques, 2002). A majority of women in the criminal justice
system have a history of physical abuse, sexual abuse and interpersonal violence, often more

18

severe, frequent, ongoing, and beginning at younger ages than those in the general population
(Alemagno, 2001; Radosh, 2002).
Studies have consistently found this to be true of female detainees. Wellisch, et al. (1993)
found that 36% of the women surveyed reported they had been sexually abused as children or
adolescents, 50% had been physically abused as children or adolescents and 50% had been
physically abused as adults by husbands or boyfriends (Wellisch et al., 1993). A later study
(Bradley & Devino, 2007) conducted in a New York prison found that 59% of women had
experienced childhood sexual abuse, 70% had been physical abused by a caretaker as a child,
49% had been the victim of rape and 75% involved in interpersonal violence as an adult. Radosh
(2002) found that extreme battering was the most consistent pattern of abuse endured by
incarcerated women. Abuse occurred in higher numbers in instances where women had spent
time in foster care or institutions, or in homes where parents abused drugs or alcohol (Radosh,
2002).
Singer et al. (1995) found that women, with histories of extreme violence and abuse, used
drugs or alcohol as a coping mechanism. More than half of female detainees admitted that they
had used drugs in the month previous to arrest, and 40% admitted that they had used drugs daily
(Haywood, Kravitz, Boldman & Freeman, 2000). As many as 80% admitted to regular drug use
at the time of arrest (James & Glaze, 2006;Wellisch et al. 1993). Increased substance abuse and
involvement with drug dealing leads to more violent acts committed by women (Singer et al.,
1995/ Sterk & Elifson, 1990). Haywood, Kravitz, Boldman and Freeman (2000) reported that the
prevalence of drug use among female detainees translated to criminal offenses. Of women
surveyed, 25% indicated that they had committed offenses to obtain drugs. They found that one

19

in three females were in jail for drug related offenses and 40% admitted to being under the
influence of drugs at the time of arrest. An overwhelming majority of women in jail have
histories of abuse and substance dependence requiring mental health treatment.
Mental Health of Female Inmates
In a statistical report conducted for the U.S. Department of Justice, James and Glaze
(2006) reported that 75% of incarcerated females had a mental health problem at the time of their
arrest, a figure nearly three times the rate of male inmates. This meant that they had reported a
recent history or symptoms of a mental health problem or had received treatment or a clinical
diagnosis by a mental health professional based on DSM-IV-TR criteria within the previous year.
Teplin, Abram, and McClelland (1996) studied the prevalence of psychiatric disorders among a
large sample of women offenders in a large urban jail and found that 70% of female detainees
suffered from a major psychiatric disorder within six months prior to arrest, and 80% had at least
one lifetime psychiatric disorder with 33% qualifying for a diagnosis of PTSD (Haywood et al.
(2000).
Trauma from abuse plays a major role in resulting mental health, substance abuse, and
physical problems (Covington, 2003; Pennebaker, 1990). Traumatic experiences result in a
variety of symptomologies and dysfunctional behaviors. Trauma is a factor in a number of
mental health disorders such as mood disorders, personality disorders, anxiety disorders,
dissociative disorders, eating disorders, sexual disorders and substance abuse disorders. Abuse
experienced during childhood has been linked to a variety of problems in psychological
functioning and dysfunctional behaviors (Messina & Grella, 2006). Childhood abuse and

20

traumatic exposure have been associated with adolescent conduct problems, adult psychological
distress and specific types of criminal behavior (Grella, Stein, & Greenwell, 2005).
Co-occurring mental health disorders and substance abuse disorders are prevalent among
women inmates. Of those female detainees who are diagnosed with a mental health disorder,
75% also met criteria for substance dependence or abuse (James & Glaze, 2006). Co-occurring
substance use disorders were more prevalent among jailed women with severe mental disorders
(72%) than among psychiatric patients (30%-50%) (Haywood et al. 2000). Singer et al. (1995)
observed that women with co-occurring substance disorders were more likely to be arrested and
served longer jail sentences than those who had not. In a general population of female inmates,
49% were found to have co-occurring disorders (Covington, 2006). The special mental health
needs of women have presented a difficult challenge to correctional institutions.
Mental Health Services in Correctional Institutions
Correctional institutions have the primary purpose to protect society by confining
offenders in controlled environments that are safe, humane, cost-efficient and secure (Federal
BOP). Though the system was designed to isolate criminal behavior, it is also necessary for
correctional institutions to provide help with mental health and physical needs (Covington,
2007). According to Blitz, Wolff and Paap (2006) women offenders may be more likely to
receive mental health services than substance abuse treatment while incarcerated, and may be
more likely to get treatment in jail than in the community before incarceration. Substance abuse
treatment programs are not able to address mental health issues associated with co-occurring
disorders. Both forms of treatment must be available to inmates in order to reduce the number of
them returning to jail. While treatment accessibility presents a challenge in correctional facilities,

21

needed help is also limited in the community (Wellisch, 1993). Lack of access to integrated
treatment within the community and minimal treatment in correction facilities leads to recidivism
among offenders with co-occurring disorders, who are disproportionately women (Grella &
Greenwell, 2007).
Incarcerated women have a higher instance of substance abuse, mental health, and health
problems than their male counterparts (Alemagno, 2001; Covington, 2007; Grella & Greenwell,
2007). By most accounts, the special needs of female inmates are met with sporadic,
inconsistent, inappropriate, or inadequate programming (Radosh, p. 301) and fails to address the
issues that are most important for humanistic reasons that are most likely to enable individuals to
cope and reduce recidivism (Radosh, 2002). Haywood et al. (2000) found that many larger jails
were providing mental health screening and evaluation, suicide prevention, crisis intervention,
limited therapy, and some substance abuse treatment but recognized that these programs fell
short of meeting the needs of female inmates. According to Wellish et al. (1993) a large
percentage of jails and prisons were not providing women with adequate medical, psychological
and substance abuse treatment options in the majority of jails and prisons. Many programs
neglect some areas of treatment altogether. Teplin, Abram, and McClellan (1996) observed that
most incarcerated women with psychiatric disorders were not receiving treatment.
Once incarcerated, women face a multitude of problems requiring mental health and
substance abuse intervention and medical care. Limited institutional funding is available to
address the needs of this complex population (Radosh, 2002). Changes are needed so that the
correction systems, ill-equipped to supply the needed treatment, can develop low-cost, brief, and
effective treatment options (Covington, 2007). Henriques (2002) called for the development of

22

integrated, gender-sensitive treatments for incarcerated women, designed to address mental

health issues, trauma, and addiction. Comprehensive treatment programs are needed to facilitate
real changes in the system and in the lives of individuals and families (Covington, 2007). The
American Corrections Association has established standards for mental health treatment in the
jail setting, describing essential treatment components. However, little research has been
conducted to examine treatment efficacy for incarcerated women making it difficult to develop
treatment solutions for women in jail (Haywood, et al. 2000). Within correctional institutions,
counselors must adapt to special challenges that are less likely to be found elsewhere.
Counseling Inside a Correctional Facility
Professional counselors working with incarcerated populations face extraordinary
challenges. Inmates treatment needs are extreme, time is limited, and prisoners are resistant and
distrustful of the therapeutic process. Detainees are influenced by the social structure in jail and
perceived expectations of fellow prisoners. Often they demonstrate a reluctance to address
emotional issues and an automatic distrust for those associated with jail administration. A
heightened resistance to verbal disclosure coupled with the tendency of inmates to take
advantage of others weakness and vulnerability often interferes with effective therapeutic
interaction. Disclosure may be perceived as dangerous or threatening if inmates fear being
perceived as vulnerable by others. Inmate perception is often one of basic survival leading to the
use of rigid defenses for self protection. Inmates often feel judged by others and are reluctant to
address sensitive issues or show emotion (Gussak, 2007).
One of the first things a counselor learns when working with inmates is that correctional
facilities, unlike community agencies, are not designed to be supportive and promote

23

rehabilitation; they are designed primarily for the purpose of punishment (Kelly & Empson,
1999). First time therapists in a correctional facility may experience personal fears and feelings
of inadequacy, loneliness and intimidation. Each therapist needs to confront fears related to the
place, the patients, and the staff. Karban (1994) described her experience as jumping in at the
deep end as she entered the jail as an art therapist. She continues, This level of fear was quite
different from anything I had encountered before. I felt it as soon as I entered the building every
morning. It felt like going on to a boat that was leaving the outside world, as I left my normal
reality and entered a far more intense environment (Karban & West, 1994 p.136).
Correctional personnel often resist treatment programs because they appear contrary to
correction goals, since correctional facilities are perceived primarily as a place for punishment
(Byrne, 2005). Thus, those exercises that are designed to encourage creativity while producing
and encouraging unity, self-esteem, and empowerment, are viewed by some as contrary to the
primary purpose of correction facilities (Stanford, 2004). Staff and others with this attitude see
therapy of any kind as an option that should not be offered to inmate populations. Staff with an
antagonistic view of the presence of therapy programming can impede treatment in subtle ways.
Opposition to therapy programs result in increased inmate resistance, difficulty in establishing a
trusting therapeutic environment and impaired ability to address issues related to individual
dysfunction and recidivism (Liebmann, 1994). Just as the focus and direction of counselors
appears contrary to that of correctional staff, inmate behaviors and attitudes appear on opposite
ends of the scale.
Incarcerated people can be creative, intelligent, and capable. On the other hand, they may
also be manipulative and dishonest, having learned to recognize and take advantage of the

24

sympathies of others (Mageehon, 2003). In light of these limitations, group art therapy in a
correctional facility is still possible and potentially beneficial to the incarcerated client and the
institution. Professionals who provide counseling services to female arrestees face many inherent
challenges. In local jails, one challenge is the short-term nature of incarcerations. The length of
stay for inmates in a county jail ranges from overnight to a sentence of up to one year. The
population is moving and changing with little predictability making consistency in treatment
difficult to maintain (Henriquez, 2002). Because the focus of corrections staff is to provide
custody, care, and control, counseling programs are often met with resistance. Concerns about
compromising security and the nature of punishment engender limited support from a large
portion of corrections staff (Kelly & Empson, 1999).
Research has demonstrated that creative activities can be beneficial to both the individual
and the correctional institution. When using art therapy in prison, Gussak (2005) saw evidence of
better compliance with directives and an improvement in behavior among those treated. Gibbons
(1997) found that inmates who were able to engage in creative endeavors showed improvement
in their mental health, attitudes, and behaviors. Creativity has often been used throughout history
to process life experiences.
Expressive Arts
Expressive arts therapies are art forms ranging from those that are primarily auditory or
written to those that are predominantly visual (Gladding, 2005, p. 2) that are used in counseling.
They offer verbal and nonverbal ways of identifying, expressing and exploring feelings that may
be difficult to express verbally. Expressive arts foster different ways of experiencing the world.
They are enriching, stimulating and therapeutic in their own right. When employed in clinical

25

situations, they help counselors and clients gain unique and universal perspectives on problems
and possibilities (Gladding, 2005, p. vii). Creative arts therapies include music, dance and
movement, imagery, visual arts, literature and writing, drama and psychodrama, and play and
humor and are used individually or in combinations (Gladding). Expressive arts use can prevent
and resolve problems, enrich the lives of participants, enhance the process of change, and help
improve self-concepts and personal insight (Gladding; Pressman, 2005; Ulman, 1992). Carlson
(1997) observed theoretical similarities between the ideas of art and narrative therapies and
suggested a rationale for the integration of these two approaches in therapy. Stanford (2005)
while conducting poetry workshops in a womens prison found that the creative work assisted
inmates in coping with prison while developing images of the women they want to be. Music
therapy was used by Daveson & Edwards (2001) in a womens facility to reduce tension, stress
and anxiety while increasing self-expression.
The goal of expressive arts exercises is to stimulate emotional arousal and enhance
expression leading to catharsis and a better understanding of self. Many media sources such as
music, films, books, psychodrama and creative arts can be used effectively to help individuals
express feelings, understand their experiences, and recognize and release emotions through a
variety of artistic media (Gladding, 1992; Young & Bemak, 1996). To express the feelings is not
enough, though. It is also necessary to experience personal insight and change as a result of the
experience (Young & Bemak). In jail, Liebmann (1994) observed that crisis situations were often
eased through catharsis. Expression of pent-up emotions, reduction of feelings of isolation and
increased coping skills with difficult issues were also observed (Liebmann, 1994). Research has

26

shown that expressive arts therapies provide effective ways to help clients improve selfconcepts
and increase personal insight in a variety of settings (Gladding, 2005; Ulman, 1992).
Advantages of Expressive Art Therapies
Expressive art therapies can provide a non-threatening approach to ease into a verbal
dialogue. With its use, individuals are able to verbalize feelings and experiences that were
previously kept secret. As they express themselves, they are able to see their problems more
clearly and begin to work towards solutions (Riley, 2001). The finished art product alone does
not complete the expression, rather it comes when the feelings evoked through the exercise are
expressed to others (Liebmann, 1994). Pennebaker (1990) found that although expression in
itself was helpful, the greater benefits were recognized in the form of insight into personal
experiences over time (Ferszt, Hayes, DeFedele, & Horn, 2004).
Art and other expressive mediums have been used throughout history as a means of
helping individuals cope with the aftermath of upsetting experiences and trauma. In recent years,
it has become common practice to address these types of issues using expressive arts in a group
setting. For example, group art therapy was utilized with adolescents who had witnessed the
terrorist attacks of September 11, 2001 in New York City. Teenagers participated in a project to
process this experience by creating documentary films about the events (Tosone, Gelman, &
McVeigh, 2005). Riley (2001) suggested that art therapy helped adolescents to view problems
from a new perspective and externalize their experiences. Art therapy fosters support for youth
who have experienced abuse, depression, low self-esteem, and feelings of failure (Riley).
Creative mediums such as art, music, dance, and drama enables the expression of deeper
emotions and pain than is possible with verbal therapy. Wilson posited that the therapists

27

primary responsibility is to serve as a witness or guide while clients make personal

interpretations of their own work. Art therapy techniques help clients access deep feelings and
memories and may expose hidden issues never expressed previously (Wilson, 1998). For
inmates, creative expression provides socially acceptable coping skills by providing an emotional
escape from the challenges experienced while incarcerated (Gussak, 2007; Liebmann, 1994). The
work of Richards, et al. (2006) established that traumatic and upsetting experiences lead to
physical, mental, psychological problems. Art therapy provides a socially acceptable way of
expressing difficult experiences often considered inappropriate to express in other ways
(Malchiodi, 2005). Through written and visual expression the health and behavior of the inmates
was improved (Gussak, 2006; Richards, et al., 2006).
Another benefit of creative therapies is its unique ability to by-pass client defenses such
as dishonesty and denial (Wilson, 1998). In many treatment situations, art therapy or another
creative medium may be utilized to encourage clients to discover and express feelings that are
difficult to express verbally (Ferszt et al. 2004; Gladding, 2005; Malchiodi 1998, 2003).
According to Gussak (2006), art therapy encourages simplified expression of difficult concepts.
It allows inmates and others to disclose emotions visually when they may not be comfortable or
able to disclose verbally. In her work with a death-row inmate, Eisdell (2005) used visual
expression to communicate where the client refused to do so verbally. Working with traumatized
women, Wilson observed that most clients are willing to participate in creative activities after an
initial hesitation.

28

Effectiveness in Correctional Facilities

Liebmann (1994) explained the factors leading to a successful implementation of art
therapy in prison. Foremost, creative therapeutic intervention requires emotional risk. If
successful, clients leave with a renewed curiosity about themselves and others. Images bypass
well-practiced defenses. Visual expression can assess deeply held feelings and memories and
open up issues that have been hidden or obstructed by denial and repression. Over treatment, it
leads to a more direct expression of emotions through the use of images rather than words. Art
therapy has the potential to engage even those individuals that are withdrawn and depressed,
while alleviating feelings of isolation and desperation (Liebmann).
Incarcerated clients are ideal candidates for art and other creative therapy interventions.
Their ability to express emotion is often severely limited by their setting and by their verbal
skills (Eisdell, 2003; Ferszt et al., 2004; Young & Bemak, 1996). In a correctional facility,
inmates withdraw in order to avoid criticism and disciplinary action (Gussak 2006). This
treatment medium engages them through active participation, by encouraging creativity, and
addressing difficult issues with a sense of play (Liebman, 1994). Individuals who have difficulty
expressing feelings because of rigid defenses will benefit more from expressive therapies than
those who are already adequately expressive or over-expressive. Young and Bemak concluded
that those individuals who are under expressive may benefit most from expressive therapies.
Due to the difficulty in administering individual treatment in a jail setting, group therapy
is often used (Merriam, 1998). This treatment medium requires active participation engaging
clients in the process, encouraging creativity, and addressing difficult issues often with a sense of
play (Liebmann, 1994). Malchiodi (2003) found that art therapy groups utilized the curative

29

factors identified by Yalom (Yalom & Leszcz, 2005) including: instilling hope, enhancing
interaction, promoting universality, providing catharsis, and allowing altruism. Because of the
isolation of incarcerated individuals, group work can be an important therapeutic tool for those
who are in detention facilities. When the benefits of creativity for incarcerated individuals is
considered, it is easy to recognize the necessity of investigating group art therapy in corrections
facilities (Gussak, 2006).
Even without encouragement, creativity emerges in the form of drawings, tattoos,
carvings, and crafts. According to Harrington (1997) art is one of the few legitimate profitmaking enterprises in incarcerated settings. Inmates create a variety of items including portraits,
crafts, and greeting cards that are traded for commodities and personal items (Harrington, 1997).
Creative activities allow inmates to experience autonomy, self-expression and self-exploration,
and provide them with opportunities to express emotions in an institutional setting that is rigid
and controlling. Emotional expression while incarcerated sometimes leads to negative
consequences from other inmates or staff. Expression through art and writing facilitates intense
expression in acceptable and appropriate ways. Art has been prevalent in incarcerated settings
(Gussak 2005).
Expressive Writing
Researchers concluded that expressive writing had been shown to improve physical
health of persons who tend to be more inhibited, high in hostility, and are members of
stigmatized groups (Richards, Beal, Seagal, & Pennebaker, 2000). Pennebaker (1990) theorized
that unexpressed emotions led to physical, mental, psychological problems and monitored
physical responses as evidence. He and his colleagues found expressive writing effective in

30

reducing infirmary visits among psychiatric prison inmates who were dealing with traumatic
events (Richards et al). Further examination of his results led him to the conclusion that benefits
from expressive writing treatments had long-reaching effects and were tied to the individual
gaining greater self-understanding and insight into their experiences (Pennebaker). Bradley &
Follingstad (2003) combined expressive writing and Dialectical Behavioral Therapy with
incarcerated women who had experienced interpersonal violence. They found it to be effective in
reducing PTSD, mood, and interpersonal symptoms and suggested that future research may be
beneficial which incorporates other active interventions.
Pennebakers (1990) theory of inhibition is based on the idea that individuals who fail to
express upsetting emotions become physically and psychologically ill. In his studies he
encouraged participants to disregard rules for writing and record whatever they felt best
described upsetting and traumatic experiences. He monitored physical symptoms and visits to
health facilities. Based on his results, writing therapy efficacy increased with the frequency of
emotional words in the writing samples (Frattaroli, 2006). An overwhelming majority of
participants benefited from improved personal insight and a better understanding of themselves
and their experiences.
Art Therapy
One of the expressive therapies that has been used most successfully in corrections
facilities is art therapy. Art therapy, often considered an adjunct to psychotherapy, can be an
effective treatment modality in a variety of settings (Rubin, 2001). The American Art Therapy
Association has defined art therapy as the therapeutic use of art making, within a professional
relationship, by people who experience illness, trauma, or challenges in living (American Art

31

Therapy Association, 2005, p. 1). Treatment using art therapy involves the use of art in the
service of change on the part of the person who created the artwork (Merriam, 1998, p. 9).
Each experience with art therapy provides an opportunity for growth and insight. Fillip
(1994) elaborated on the value of a single art therapy session. She found that one experience of
art therapy could potentially reawaken a sense of play, creativity and spontaneity. A single
experience could help to establish a positive attitude about therapy and promote an increase in
personal awareness. Riley (2001) posited that art is can serve as a non-threatening invitation to
begin verbal dialogue. Illustrating the problem allows the individual to see problems from a new
perspective.
The artwork becomes the focus and clients are able to distance themselves from their
problem and begin to work toward solutions (Riley, 2001). Given the opportunity, clients are
able to address the meaning of their own work while the therapist can help them to explore its
meaning. Interpretation is ultimately up to the artist (Wilson, 1998). Wilson (2000) suggests that
art therapy helps to develop a personal language of expression through images. Artistic
expression fulfills both emotional and psychological needs, gives form to chaos, helps to master
anxiety. She also found it helpful in dealing with addiction, feelings of powerlessness, and the
feeling that life is unmanageable.
The art therapy treatment medium requires active participation, engaging clients in the
process, encouraging creativity, and addressing difficult issues often with a sense of play
(Liebmann, 1994). Ulman (1992), a pioneer in art therapy, describes art therapy as more than a
springboard for the patients verbal association. She believes that the arts can make contribution
to therapy that are not available in other mediums. She emphasizes the importance of both art

32

and therapy in treatment, that art is not therapy on its own. Therapy is not enough, art is not
enough either (Rubin,1999, p. 63).
Art Therapy for Trauma Treatment
Art therapy combines the inherent healing capacities of the creative process with the
informed use of psychological principles integrating the essentials of creativity and healing. In a
sense, art therapy provides an alternative language for examining and expressing human
experience (Rubin, 1984). Researchers have discovered that traumatic memories are often stored
in the mind in visual form. Thus visually expressing difficult memories may be more intuitive
than verbal expression (Malchiodi, 1998). Art therapy is a modality with special qualities for
reparation, transformation, and self-exploration (Malchiodi, 1998, p. 9). Merriam (1998) agreed
that incarcerated women present with a wide range of treatment challenges due to the repeated
traumas they have experienced including sexual and physical abuse such as incest, rape and
physical assault. In addition, they suffer from extreme emotional effects such as fear, depression,
anger, terror, grief, anxiety, rage and present with eating disorders, substance abuse, dissociation
and self-injurious behaviors and suicide attempts (Merriam). Women detainees have experienced
multiple loss and exhibit extreme symptomology which requires increased sensitivity in
treatment. Merriam observed that art images enabled women to reconnect with upsetting
thoughts and feelings safely (Merriam).
Merriam (1998) described some of the unique benefits of the use of art therapy with
incarcerated women who had experienced severe trauma. Art therapy helped women with
Dissociative Identity Disorder (DID) to facilitate connections among alters (Liebmann, 1994).

33

In her work with women who had experienced trauma, Gerity (1997) indicated that the clients
most often drawn to art therapy were those who had been diagnosed with borderline personality
disorder, dissociative identity disorder and PTSD, and/or who shared a history of various kinds
of trauma or abuse. These clients seemed better suited for art therapy than for verbal groups due
to the visual storage of traumatic experiences. Her explanation was that much of the trauma
occurred before clients had developed language. Consequently, they were more accessible
through art therapy (Gerity).
Art therapy benefits women who have been traumatized by providing a protected
environment for lowering defenses, releasing tension, and providing opportunities for insight. It
has also proven helpful in gaining access to information that clients have repressed, denied or
dissociated. Art therapy can also help to foster improved self-soothing in women who have been
abused (Liebmann, 1994; Merriam, 1998).Wilson (2000) utilized art therapy techniques focused
on shame related to trauma and addiction. This shame results in feelings of unmanageability and
powerlessness, and a continuation of dysfunctional behaviors. Shame is difficult to verbalize and
more easily expressed through imagery and symbolism. Through art therapy, they are
empowered to begin the process of recovery (Wilson, 2000).
Art Therapy within Correctional Facilities
Several facets of prison life and culture render art therapy an effective treatment for
inmates. Emotional expression while incarcerated sometimes leads to negative consequences.
Verbal expression of some emotions may be viewed by correctional staff and other inmates as a
weakness, or as a threat (Ferszt et al., 2005). However, art and writing exercises facilitate intense
expression in acceptable and appropriate ways. Art has been a prevalent pastime in incarcerated

34

settings (Gussak, 2005). Inmates, already comfortable with art and creativity, transition
effectively to a therapeutic use of art. (Ferszt et al., 2005).
The ability of art therapy to overcome obstacles to verbal communication has been
demonstrated in a correctional setting. It also equalizes individuals on the basis of education and
literacy (Gussak, 2005). Cronin (1994) argued that art therapy is especially effective with women
in prison because it is a place of great uncertainty. While incarcerated, women face a separation
from family, friends, and familiar surroundings, long periods of waiting, stress of appearing in
court, and lack of communication with family, which all contribute to anxiety and feelings of
insecurity. In addition, prison is associated with punishment, loss of freedom and choice.
Offering therapy with its implication for change, and empowerment, sometimes seems to clash
with the prison environment. Some view prison as a pause, or a break from their stressful
existence outside jail, which enables inmates to step back and reevaluate life patterns. Visual
images in the form of art enables prisoners to associate with several experiences simultaneously
and make links between the content of therapy sessions, prison and offending behavior (Cronin).
Creative expression provides socially acceptable coping skills by providing diversion and
emotional escape from the challenges of prison life (Gussak, 2007; Liebmann, 1994). Gussak
found that the art therapy participants attitudes improved, their acceptance of one another and
the environment increased, and there was better interaction between staff and peers. (Gussak,
2005). Inmates utilize art as a means to cope with the drab sterile environment and dragging time
of prison life. Art therapy encourages simplified expression of difficult concepts, and allows the
inmate to disclose visually when he may not choose to or feels unable to disclose verbally
(Harrington, 1997).

35

Through the use of art therapy a permanent tangible record of the therapeutic process is
available for observation and continued discussion with the client and could serve as a record
and a reminder of insights and growth (Ferszt, et al., 2004; Pennebaker, 1990). In the event that
the images are difficult to talk about at the time they are created they can be revisited when the
issues can be addressed (Wilson, 1998). At any point the therapist or the client can refer back to
stimulate or reinforce therapeutic work with an accuracy that is not possible with verbal therapy.
Client art work can also be viewed chronologically to identify emerging patterns and cite
therapeutic progress (Hanes, 2001).
In an attempt to establish more quantitative evidence of the effectiveness of art therapy
against depressive symptoms, Gussak (2007) conducted consecutive studies with male inmates.
His studies took place in a state correctional facility. Inmates participated in art therapy sessions
over a period of eight weeks. Testing instruments were administered at the beginning of
treatment and again at the conclusion of the treatment. Results from the Beck Depression
Inventory-Short form (BDI-II) indicated significant improvement in depressive symptoms,
however, the results were inconclusive using the Formal Elements Art Therapy Scale (FEATS).
Although the initial study did not have a control group, subsequent studies were compared to a
similar group of inmates who did not receive art therapy treatment. This important research
resulted in long term research placement for art therapy in the state prison system. Other positive
effects observed in this study included decreased depression, improved mood and attitude, better
inmate behavior, improved socialization skills, and increased compliance with staff and facility
rules. (Gussak, 2004a, 2006b, 2007c).

36

Arts Therapy in Groups

Creating art in a group setting adds unique benefits to working alone (Malchiodi, 1998).
Waller (2003) stated that producing images in a group setting added a dimension to
communication and expression that could not be achieved while working alone. Using art
therapy in group settings allows each individual to work at the same time to illustrate their
feelings and then find support from others as they share these feelings verbally (Gladding, 2005).
Because all of the members of the group have shared the experience of creating the art, they are
more likely to be empathetic and receptive to giving and receiving feedback to one another
(Waller). In treatment groups people can share traumatic material within the safety, cohesion,
and empathy provided by other survivors (Collie, et al. 2006; Pressman, 2005). Although
individuals learn from their own work, there is an added effectiveness to the group as they view
the artwork of others and listen to their stories (Samuels, 1994).
Creative arts therapy can be adaptable to large groups where counselors have limited time
for treatment. In a group of this kind, each participant is able to be personally involved in their
own treatment work and each gain personal insight required to address difficult issues (Kahn &
Villanova, 1999). Women inmates share common issues and gain increased insight as they view
others work while hearing about their experiences in group discussions. This allows a connection
on a more personal level and broadens the opportunity for insight and growth (Kahn &
Villanova; Samuels, 1994).
Anticipating an increase in military personnel suffering from trauma, Collie, Backos,
Malchiodi, and Spiegel (2006) recommended art therapy in group settings. They proposed that it
would provided efficient and effective treatment for combat related PTSD. Art therapy provides

37

for them an effective means to address avoidance, emotional numbing, and other symptomology.
When used in a group format, clients are able to share traumatic experiences and express
empathy with others in a safe, cohesive, trusting environment. Art therapy and group therapy
have been used effectively in the past to help individuals who were traumatized by war (Rubin,
1968). This treatment enables non-verbal expression, relaxation, externalization, containment,
symbolic expression, and the pleasure of creation (Collie, et al., 2006).
Because of the isolation of incarcerated individuals, group work can be an important therapeutic
tool for those who are in detention facilities (Liebmann, 1994). When coupled with the known benefits
of creativity for this population, a strong case can be made for continuing to investigate group art
therapy in detention facilities. Art therapy is adaptable to large groups where counselors have limited
time for treatment while availing each participant with the personal involvement and insight required to
address difficult issues (Kahn, & Villanova, 1999). Women inmates share common issues and may
benefit from viewing the work of others while hearing their stories and can often relate to the experience
on a personal level (Kahn & Villanova; Samuels, 1994).
This review of the literature indicates that art therapy has been used with incarcerated
individuals. Literary sources are primarily anecdotal in nature exploring the use of art therapy in a
variety of settings with generally positive results. However, empirical research is limited. This study is
designed to provide additional empirical data addressing the usage of group art therapy with incarcerated
women.

38

CHAPTER THREE: METHODOLOGY

This research study was designed to empirically test the effect of art therapy techniques
used with incarcerated women measured by psychological outcome scores. The treatment
consisted of a variety of art therapy treatment exercises used with a group of incarcerated women
over a three week period of time. The treatment group and the control group were pre and posttested with instruments to assess trauma and psychological distress. This chapter describes the
methodologies, considerations, and procedures used to conduct this study.
Research Question
Are expressive arts treatments effective in decreasing symptoms of trauma and
psychological distress in incarcerated women?
Research Design and Limitations
This study is a quasi experimental design comparing two groups of incarcerated women.
Women from two county correction facilities in the Southeastern United States participated in
the study. Control and treatment subjects were obtained from both institutions. The treatment
group received art therapy treatment while the control group received the mental health services
available to all inmates in the correctional facility. Art therapy participants met twice weekly for
three weeks for a total of six sessions. Pre and post treatment measures were administered to all
subjects at the beginning of the first session and following the last session. Demographic
information was collected using a separate survey to help better characterize the participants of
the study. A post study evaluation questionnaire was completed to obtain participant reactions to
their experience with the study.

39

Groups for this study were conducted by the primary investigator. Working in a
correctional facility can be intimidating for someone entering this environment for the first time.
Prior experience working with inmates in a corrections setting allows the therapist to be prepared
for the atmosphere and procedures inherent in jails. Though the counselor neednt be an artist or
art therapist, experience and understanding of the art therapy medium is essential. Inmates are
sometimes difficult clients, experience and confidence in the counseling profession is important
to the effectiveness of the study.
Participants
Participants were incarcerated women over the age of 18. Correctional facility rules
eliminated anyone whose incarceration was related to extreme violence or those individuals
being held temporarily for federal matters. The initial sample number (N=50) began the study by
completing a demographic questionnaire and outcome measures. Of those 50, 26 were
completers, with 12 in the control group and 14 in the treatment group.
Women inmates are housed in dorms called pods and spend all of their time in relative
proximity to one another. This made confidentiality difficult to maintain even though
participants were asked to refrain from discussing their treatment outside of the session. For this
reason and practical requirements of the correctional facility, treatment groups were assigned by
dorm. This also helped to simplify the process of assembling the participants and escorting them
to and from the treatment location by correctional staff.
Approval Procedures
Approval procedures included an application to the Director of Corrections and programs
staff at the John E. Polk Correctional Facility, Seminole County, Florida, and the Lake County,
40

Florida Correctional Facility. Each facility was supplied with a description of the study and all
treatment materials. Procedures for obtaining authorization for conducting research inside
corrections facilities differ according to each organization. The primary investigator complied
with a background check and attended a volunteer security training session before receiving
approval to enter the facilities. The study was conducted in compliance with all regulations set
forth by the American Corrections Association and the National Commission on Correctional
Health Care. Institutional Review Board (IRB) applications were submitted and approved
through the University of Central Florida (see Appendix A).
Recruitment and Enrollment Procedures
A flyer was displayed in pods where female inmates were housed which described the
study and asked for volunteers for participation (Appendix B). They were invited to attend an
introductory session where they would learn about the study, trauma, and related symptomology.
They were informed that participation was voluntary and that they had the option to drop out at
any time without negative consequences. They were informed that their participation would have
no effect upon their standing in the jail and that they would receive no tangible rewards such as
money or goods for participation according to corrections regulations. They were assured that
personal information, drawings, and test results would be kept confidential and that all drawings
would be returned to participants. The women were further informed that the results of the study
would be shared with the correctional administrators and potentially published, but would not
include any individual identifying information. Informed consent agreement forms were
discussed and completed at the beginning of the study (Appendix C).

41

Each participant was assigned a confidential identification number which was used to
identify treatment work and research instruments. These numbers coincided with a master list of
participants kept by the primary investigator in a password protected file on a laptop computer
and were used only to ensure that instrument scores were matched appropriately when recorded.
Participants were asked to refrain from adding identifying information to their drawings and any
inadvertent use of names were blacked out before the work was viewed or photographed.
Treatment Procedures
Art therapy groups were held in a classroom inside each facility. All sessions consisted of
a brief introductory discussion that clarified concepts, stimulated introspection, and described
treatment exercises. Materials were issued and participants were given time to complete each
sessions treatment work (45 minutes to one hour). Each session concluded with a group
discussion where each individual talked about their drawing as well as feelings and insights
about the experience. All sessions lasted between 60 and 90 minutes.
All materials required for the interventions were provided by the primary investigator.
All regulations concerning appropriate materials for inmate use were strictly observed. Materials
included drawing paper, water-based markers, crayons, and pencils. These materials were chosen
because they were inexpensive, non-toxic, required little clean-up and most clients were
comfortable using them. During the sessions, participants were able to use their choice of the
materials offered which included unlimited paper. In a jail setting, it is necessary to inventory all
drawing materials before ending the session as a precaution that materials may be stolen and
misused by inmates according to jail regulations.

42

An emphasis was made in every session to discourage self-consciousness about drawing

expertise. Participants were informed that art therapy was not concerned about the final product
quality, but rather concerned about the thinking involved. They were informed that their drawing
ability would compare to the drawings they had done as a child, and that these results were
acceptable for study purposes. The simplicity of the drawing materials also contributed to the
basic quality of drawings, as they were the materials commonly used by children.
Six art therapy exercises were chosen to address issues commonly experiences by women
related to incarceration, trauma and addiction (Appendix D). The first sessions were designed to
help establish comfort with the art therapy medium, establish group norms, and begin to develop
trust between the therapist and group members. Each subsequent exercise by design increased in
intensity and depth evoking deeper feelings while encouraging increased client insight and
disclosure. Exercises contained opportunities for creative thinking and humor to ease self
consciousness about each individuals ability to draw and to enable expression.
Each drawing exercise was designed to help participants begin to address issues related to
trauma and incarceration. For some, this was their first exposure to therapy of any kind. The first
exercise, My Happily Ever After, directed participants to think about what the phrase would
mean to them individually (Boothroyd, 1995). They were asked to identify the elements they
would like to have in their lives that they believed would lead to happiness then illustrate these
ideas. This exercise was mild in intensity so that participants would have a better idea of what
would be expected of them in the program. It also contributed to the beginning of the
development of group cohesion and a therapeutic relationship.

43

Exercise two, Masks, required additional introspection and self-disclosure (Malchiodi,

(1998). The session began with a discussion about masks, how and why people use them,
examples of masks observed in others and the positive and negative effects of wearing masks.
For those who were especially uncomfortable with drawing, the option of beginning their
drawing with an outline of a mask was introduced Participants were asked to identify the masks
they wear to protect themselves or to hide the truth.
Exercise three, The Child Within, was based on Bradshaws (1998) concept that three
voices or roles can be identified in our thoughts. These include the child voice, the parent voice
and the adult voice, each influencing our ability and methods for making decisions. This concept
was difficult for participants to grasp and it became necessary to alter the concept of the drawing
exercise. Through guided imagery, volunteers visualized themselves as children and identified a
particularly traumatic experience they had during childhood. These were illustrated and
discussed. The concept was considerably easier to grasp. The original concept was too
complicated for a beginning group and might be more appropriate with a group who had had
more therapeutic involvement.
Exercise four, Monsters, was based partially on concepts introduced by Malchiodi
(1998). During the introductory discussion, participants explored the concept of monsters. What
are their characteristics, what feelings do monsters evoke, are they the same for everyone?
Participants were asked to identify one or more personal monsters in their lives that fit the
qualities discussed. This exercise provided an opportunity to address serious issues with humor
and contributed to group cohesion and comfortable and appropriate self-disclosure.

44

Exercise five, My Most Upsetting Experience, originated from Pennebakers (1990) work
with expressive writing. He asked study participants to write about the most upsetting experience
they could share that they had never shared before. Participants were asked to illustrate their
most upsetting experience. Early in the discussion, it was obvious that the concept was
overwhelming to group participants. They were required to review a lifetime of difficult
experiences in order to identify the most upsetting. Group members were hesitant to begin
drawing, silent and unresponsive. The exercise was modified by reducing the size of the task.
The assignment was limited by narrowing the time of life to either childhood or adolescence.
Group members were then able to identify a specific experience and complete the exercise. This
exercise was effective after the changes were made.
Exercise six, Lost and Found, was designed as a termination exercise for the group. The
opening discussion encouraged participants to think back over traumatic experiences and identify
the losses and the gains that may have resulted from difficult experiences. Participants were
encouraged to identify strengths or knowledge gained that may be viewed in a positive way as
well as the real losses they had experienced. When drawings were shared, group members
discussed how traumas had changed their lives and how they could be dealt with in the future.
Women in the treatment group and the control group had access to other psychiatric
services routinely made available within the correctional facilities. Mental health professionals
provided mental health status assessments, psychiatric referrals, medication management, and
mental health observations. Psychoeducational groups were offered related to addiction, anger
management, domestic violence, and related topics. Inmates at their own discretion or by referral
attended life management sessions and Alcoholics Anonymous or Narcotics Anonymous

45

meetings. Upon release, inmates were provided with referrals to services in the community for
additional services. Records of inmate participation data in these groups were not accessible.
Instruments
Four instruments were used to gather data for this study. A demographic questionnaire
developed for this study was used to gather information about the participants which included
age, marital status, education level, number of children and their custody status, reason for
incarceration, substance use history, incarceration history, and mental and medical health history
(Appendix E). The Trauma Symptom Inventory (TSI) and the Outcome Questionnaire (OQ-452) were used as pre-test and post-test measures. At the conclusion of the study participants
completed a short questionnaire with open-ended questions to describe their experience in the
study.
Trauma Symptoms Inventory (TSI)
The Trauma Symptoms Inventory (TSI) (Briere, 1998) was designed to evaluate acute
and chronic traumatic symptomatology in adults. The measure was a self-report instrument that
consisted of 100 items describing trauma-related symptoms rated on a 4-point Likert scale (0 =
never, 3 = often) and their frequency of occurrence over the preceding six months. The test was
written on a fifth to seventh grade reading level and required approximately 20 minutes for
completion. Scores reflected ten symptom domains: Anxious Arousal (AA), Depression (D),
Anger/Irritability (AI), Intrusive Experiences (IE), Defensive Avoidance (DA), Dissociation
(DIS), Sexual Concerns (SC), Dysfunctional Sexual Behavior (DSB), Impaired Self-reference
(ISR), and Tension Reduction Behavior (TRB). It also provided three validity scales that
indicated atypical responses (ATR), response level (RL), and inconsistent responses (INC)
46

Outcome Questionnaire (OQ45.2)

The OQ-45.2 (Outcome Questionnaire) developed by Lambert and Burlingame (1998) is
a 45-item self-report questionnaire designed as a brief screening and outcome assessment scale
that measures subjective distress as well as the effects of this stress on how individuals function
in the world. (Lambert, et al., 1998). The instrument can be completed in approximately 10-15
minutes and was written at a sixth grade reading level (Hanson, 2007; Merker, 2007). The
questions were rated on a five-point Likert scale ranging from never to almost always. In
addition to the total score, the OQ-45.2 measured how a person was feeling, getting along with
others, and how they were functioning in important life tasks, with three sub-scores: symptom
distress (SD), interpersonal relationships (IR), and social role and occupational functioning
(SR).This instrument has been shown to be sensitive to change and was designed for repeat
administrations. The OQ45.2 has been found to be broadly applicable across ages, diagnoses,
treatment modalities and clinician orientations (Hanson, 2007; Merker, 2007)
Demographic and Post-test Questionnaires
A demographic questionnaire was used to identify information including age, ethnicity,
education level, marital status, number of children and their custody standing, substance use
history, incarceration history, and mental and medical health history (Appendix E). This
instrument addressed inmate issues such as the cause for incarceration, number of times the
inmate had been incarcerated, substances used, along with past and present mental and medical
diagnoses. The follow up questionnaire contained a series of short answer questions that
encouraged participant feedback about the study. Attendees were asked to identify how the
experience was positive or negative, if the treatment had been enjoyable, whether or not they

47

considered the experience to be beneficial or worthwhile, and if they would recommend the
group to others (Appendix F).
Data Collection Procedures
Four self report instruments were administered in a group setting according to the
administration procedures provided with each test instrument. At the beginning of the study,
participants completed the demographic questionnaire, the OQ-45.2, and the TSI. The
instruments were issued to participants in a large envelope marked with a confidential
identification number on the outside which coincided with a master list. Each inmate entered the
number on the questionnaires, completed the instruments, and placed them back in the envelope
for collection. At the conclusion of the study, a similar procedure was followed with care taken
to match individuals using the same confidential identification number as was initially used for
the completion of the OQ-45.2, TSI, and post-test evaluation questionnaire.
Data Analysis
Data was entered into and analyzed using Statistical Package for Social Sciences (SPSS)
13.0 for Windows Student Version. An Independent t test was used to compare pretest scores to
establish equality of variance. Pre and post-test TSI and OQ-45.2 scores were compared using
paired sample t-tests. Effect size was calculated using a Pearsons correlation (Field, 2005). A
multivariate analysis of variance (MANOVA) was used to identify interactions between the
subscores and identify potential type I error introduced by using multiple t tests. Frequencies
were calculated using the information contained in the demographic questionnaire.

48

Summary
This chapter describes the methodology applied to test the effectiveness of art therapy
treatment with incarcerated women. Two groups participated in this quasi-experimental study,
one group participated in art therapy sessions over three weeks, the other received standard
treatment provided through the correctional facility. The procedure for conducting the groups
and exercises used are discussed and outlined. Each participant completed psychological
outcome questionnaires before and after the treatment to test the effectiveness of the treatment in
decreasing symptoms of trauma and psychological disturbances. All treatment groups and testing
were administered between November, 2007 and April, 2008. The results of this study provided
information regarding the use of group art therapy with female prisoners.

49

CHAPTER FOUR: FINDINGS

This chapter contains a summary of information obtained from demographic
questionnaires, two outcome measures, and post-study qualitative evaluations completed by the
participants. The demographic questionnaire provided background information on the
participants including ethnicity, family background, legal infractions and trauma experienced.
The two outcome instruments used at pretest and posttest were the Outcome Questionnaire (OQ45.2) (Lambert & Burlingame, 1998) and the Trauma Symptom Inventory (TSI) (Briere, 1998).
Data from the OQ45.2 and TSI were entered into SPSS. Tests performed are described and the
results are reported. Qualitative results of the treatments are reported, including participant poststudy qualitative evaluation responses with feedback on the perceived value and efficacy of the
study.
Study Participation and Data Collection
Fifty incarcerated women in two county correctional facilities were initially enrolled in
the study and completed preliminary measures including the demographic questionnaire and
psychological outcome measures (TSI and OQ-45.2). Participants were assigned to treatment
groups according to living arrangements. Thus, those in the control group were not in the same
dormitories as those in the treatment group. Of the original 50 volunteers, twenty-six women (N
= 26) completed the study including retaking the psychological outcome measures and the
qualitative post-study evaluation. Figure 1 illustrates the reduction of group numbers. Due to the
transient nature of individuals in the county jail environment twelve participants were eliminated
from the study due to various administrative legal actions. Four subjects chose to withdraw and

50

three additional subjects were removed for disciplinary reasons. Five subjects discontinued for
undisclosed reasons leaving 26 subjects completing the study.
According to test creator recommendations, some scores were considered invalid and
were not included in the statistical analysis. OQ-45.2 guidelines indicate that total scores of 20 or
below are invalid, resulting in two subjects not being included in the analysis. Remaining OQ45.2 scores included 13 individuals in the art therapy treatment group and 11 in the control
group. The TSI contains three validity scales that evaluate lack of response or inconsistent and
atypical responses that may invalidate the instrument. Scores for one subject were outside these
limits and were therefore eliminated before statistical analysis was conducted. The final TSI data
included 14 in the art therapy treatment group and 11 in the control group.

51

50 Volunteers

5 Subjects transferred to another dorm or facility

7 Subjects released from jail

4 Subjects chose to withdraw

3 Subjects received disciplinary removal

5 Subjects discontinued for unknown reasons

26 Subjects completed study

2 Subjects OQ-45.2 scores invalid

1 Subject TSI scores invalid

Measure
OQ-45.2
TSI

N
24
25

Treatment
13
14

Control
11
11

Figure 1 Attrition Flow Chart

Demographic Summary
In the initial session, participants were asked to complete a demographic questionnaire.
When asked about ethnicity, participants responded 52% white, not Hispanic Origin, and 48%

52

Black or African American. Ages ranged between 20-50 years old with the mean age of 31.24.
The majority of study participants were mothers (80%). Of those participating, 24% were
incarcerated for the first time, while 76% reported previous jail terms. Times incarcerated ranged
from 1-25 with 6.25 representing the average number of times in jail. Over half of study
participants (52%) reported that members of their immediate family had been incarcerated or
were incarcerated at the time of the study.
Nearly half of participants (48%) reported a history of physical abuse and/or sexual
abuse, (36% before the age of 20) and 32% reported physical abuse and domestic violence.
Medical diagnosis was reported at 28% and mental health diagnosis at the same rate. In addition,
nearly a fourth (24%) reported having been hospitalized in a mental health facility. Nearly half
(48%) of participants chose not to answer questions related to drug use while 36% reported that
they regularly used drugs and alcohol with 28% admitting to being under the influence at the
time of arrest.
Participants were asked to describe the charges leading to their incarcerations. Responses
included charges related to drugs, which included possession of drugs and drug paraphernalia,
purchasing drugs, trafficking drugs, fraud and forgery charges, robbery, burglary, grand theft,
and grand theft auto. Some were arrested for violation of probation and driving violations such as
driving without a valid license, hit and run, and driving under the influence. Only two were
charged with violent crimes such as assault with a deadly weapon, and battery, and one was
arrested for failure to comply as a sex offender. Two individuals did not respond to this item. In
most cases, individuals were arrested for more than one charge.

53

Statistical Analyses
It was assumed that population variances between the treatment and control groups were
the same at the beginning of the experiment. Following the data analysis pattern found in similar
tests reported in the literature (Gusssak, 2006; Pifalo, 2006), an independent samples t test was
performed to test this assumption using the initial scores on the OQ-45.2 (Table 1) and the TSI
(Table 2). As previously indicated in Figure 1 the OQ-45.2 scores included 13 individuals in the
art therapy treatment group and the control group included 11 individuals. The analysis for the
TSI included 14 individuals in the art therapy treatment group and 11 in the control group.
The independent t test for the OQ-45.2 supported the assumption of homogeneity of
variances for scores on the Total and all subscales, including Symptom Distress (SD),
Interpersonal Relations (IR), and Social Role Performance (SR) (Table 1). The data in the table
shows means (M), standard deviations (SD) and the degrees of freedom (df) for both the art
therapy and control groups. The data in the t test (t) column show t = .813, .629, -.516, and .586
for SD, IR, SR and Total respectively. Statistical significance is .425, .535, .611 and .586 for SD,
IR, SR and Total respectively, none of which approach significance at the p = .05 level.
Pearsons r data as seen in Table 1 range from .167 to .121 across the scores, all of which
indicate a small effect size.

54

Table 1. OQ-45.2 Scores for Art Therapy and Control Groups at Pretest

OQ Score

Symptom
distress

Interpersonal
relations

Social role
performance

Total score

Group

M SD

Art therapy

37.31 (10.77)

Control

32.83 (16.39)

Art therapy

19.46 (6.24)

Control

17.67 (7.98)

Art therapy

10.38 (4.21)

Control

11.25 (4.16)

Art therapy
Control

67.15 (18.21)

df

significance

23

.813

.425

.167

23

.629

.535

.130

23 -.516

.611

.121

23

.563

.121

.586

61.75 (27.31)

p < .05

Table 2 follows the same pattern as found in Table 1, but provides statistical analysis on
TSI pre-scores utilizing the independent t test. The test assumption again was that there was no
variance between the pre-treatment test scores of the treatment and control groups. With one
exception the assumption of homogeneity of variances between the two groups was established.
Data for Anxious Arousal (AA), Depression (D), Anger/Irritability (AI), Defensive Avoidance
(DA), Dissociation (DIS), Sexual Concerns (SC), Dysfunctional Sexual Behavior (DSB),

55

Impaired Self Reference (ISR) and Tension Reduction Behavior (TRB) produced non-significant
t tests and all Pearsons r results indicated small effect sizes. The exception was the Intrusive
Experiences (IE) scale where the group did not meet the assumption of homogeneity and equal
variances could not be assumed according to Levenes test for equality of variance (p = .03).
Therefore, Table 2 reports M, SD, df, t, significance and r for the alternate hypothesis on this
scale, supporting unequal variances between the art therapy and control group at the beginning of
the study for this scale.

56

Table 2. TSI Scores for Art Therapy and Control Groups at Pretest

TSI Scale

Group

M SD

Art therapy

52.57 (9.53)

Control

52.18 (13.75)

Art therapy

55.00 (9.17)

Control

53.64 (8.93)

Art therapy

57.29 (11.38)

Control

54.09 (10.36)

Art therapy

61.57 (7.52)

Control

58.91 (13.13)

Art therapy

62.07 (8.98)

Control

59.36 (12.48)

Art therapy

57.57 (8.72)

Control

53.45 (10.23)

Art therapy

54.71 (10.44)

Control

55.82 (13.69)

Anxious arousal

Depression

Anger/irritability

Intrusive
experiences 1

Defensive
avoidance

Dissociation

Sexual concerns

Dysfunctional
sexual behavior

Art therapy
Control

65.07 (16.76)
63.09 (18.86)

57

df

significance

23

.084

.934

.018

23

.373

.712

.078

23

.724

.476

.149

15

.600

.558

.153

23

.631

.534

.130

23

1.087

.289

.221

23

-.229

.821

.048

23

.278

.784

.058

TSI Scale

Impaired selfreference

Tension reduction
behavior

Group

M SD

Art therapy

57.14 (8.71)

Control

59.00 (12.01)

Art therapy

61.50 (14.83)

Control

61.36 (13.31)

df

significance

23

-.449

.658

.093

23

.024

.981

.005

p < .05
1
Levenes test for
equal variances
not assumed p <
.05

Paired-samples t tests were conducted comparing pretest and posttest scores for the art
therapy group and then the control group. These statistical analyses indicated the degree of
change within each group over the duration of the experiment. With the OQ-45.2 data with the
treatment group the SD sub-score improved significantly as did the Total score. The IR sub-score
approached significance (Table 3). Specifically, results for SD indicated that pretest scores (M =
37.31, SD = 10.77) were significantly better than posttest scores (M = 31.00, SD= 12.85), t(12) =
2.25, p < .05, (r = .544) a large effect size. Results for IR pretest scores (M = 19.46, SD = 6.24)
approached significance when compared with the posttest scores (M = 16.69, SD = 5.62), t(12) =
2.17, p > .05, (r = .53) a large effect size and the results for total score pretest (M = 67.15, SD =
18.21), and posttest (M = 57.69, SD = 22.07, t(12) = 2.34, p < .05, were also significantly
different with a large effect size (r = .56).

58

The only OQ-45.2 scores not showing improvement in the art therapy group were
associated with SR (pretest M = 10.38, SD = 4.21), and posttest (M = 10.46, SD = 4.31, t(12) = .09, p > .05, r =.025).
Table 3. Art Therapy Treatment Comparison for Pretest and Posttest OQ-45.2 Scores

OQ Score

Pretest
M SD

Posttest
M SD

df

significance

Symptom distress

37.31 (10.77)

31.00 (12.85)

12

2.25

.044

.544

Interpersonal relations

19.46 (6.24)

16.69 (5.62)

12

2.17

.051

.530

Social role performance

10.38 (4.21)

10.46 (4.31)

12

-.09

.933

.025

Total score

67.15 (18.21) 57.69 (22.07) 12

234

.038

.559

p < .05

Table 3: Art Therapy Treatment Comparison of Pretest and Posttest OQ-45.2 Scores.
The paired-samples t test comparing OQ-45.2 pretest and posttest scores for participants
in the control group indicated no statistically significant changes within this group during the
study (Table 4). However, the numerical values did improve unexpectedly even with no
treatment and will be discussed in more detail Chapter Five.

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Table 4. Control Group Comparison of Pretest and Posttest OQ-45.2 Scores

OQ Score

Pretest
M SD

Posttest
M SD

df

significance

Symptom distress

32.83 (16.39)

29.50 (19.29)

11

1.67

.123

.450

Interpersonal relations

17.67 (7.98)

13.83 (8.16)

11

1.84

.093

.485

Social role performance

11.25 (4.16)

11.08 (6.22)

11

.14

.895

.041

Total score

61.75 (27.31) 54.33 (31.45) 11

1.80

.099

.477

p < .05

Statistical comparison of TSI scores pretest and posttest for the art therapy group unlike
those previously reported with the OQ-45.2 resulted in only one of the ten scales indicating
significant change and two of the scales somewhat approaching significance. The remaining
seven scales indicated no significant change resulting from the art therapy treatment. Scores for
ISR were significant at the 95% confidence level with pretest (M = 57.14, SD = 8.71) and
posttest (M = 53.14, SD = 8.71), t(13) = 1.83, p < .05, r = .525, while scores for IE and DSB
approached significance. Scores for the IE scale were significantly improved at the 90%
confidence interval, pretest (M = 61.57, SD = 7.52) and posttest (M = 58.29, SD = 7.69), t(13) =
1.88, p < .10, r = .461, and DSB results were significant at the 90% confidence level, pretest (M
= 65.07, SD = 16.76) and posttest (M = 58.64, SD = 9.66), t(13) = 1.17, p < .10, r = .453.

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Table 5. Art Therapy Treatment Group Comparison of Pretest and Posttest TSI Scores
TSI Scale

Pretest
M SD

Posttest
M SD

df

significance

Anxious arousal

52.57 (9.53)

50.07 (8.91)

13

1.40

.186

.361

Depression

55.00 (9.17)

52.07 (7.48)

13

1.45

.170

.373

Anger/irritability

57.29 (11.38)

53.36 (11.12)

13

1.38

.191

.357

Intrusive experiences

61.57 (7.52)

58.29 (7.69)

13

1.88

.083

.461

Defensive avoidance

62.07 (8.97)

60.29 (10.08)

13

.93

.371

.248

Dissociation

57.57 (8.72)

54.71 (10.92)

13

1.69

.114

.425

Sexual concerns

54.71 (10.44)

52.00 (7.57)

13

1.17

.262

.309

Dysfunctional Sexual
Behavior

65.07 (16.76)

58.64 (9.66)

13

1.17

.090

.453

Impaired self-reference

57.14 (8.71)

53.14 (8.71)

13

1.83

.044 *

.525

Tension reduction
behavior
*p < 05

61.50 (14.83)

56.57 (9.98)

13

1.43

.175

.369

Similar to the results on the OQ-45.2 the analysis of pretest and posttest data on the
control group TSI scores generally indicated numeric improvements even though no treatment
was received, but resulted in no statistically significant improvements. Unlike the remainder of
the data the DIS scale on the TSI instrument resulted in a non-significant negative response.
Scores for the DIS scale pretest (M = 53.45, SD = 10.23) were not significantly different than
posttest scores (M = 56.73, SD = 11.70), t(10) = -1.121, p > .05, r = .334, but resulted in a 1.121
non-statistical negative response.

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Table 6. Control Group Comparison of Pretest and Posttest TSI Scores

TSI Scale

Pretest
M SD

Posttest
M SD

df

significance

Anxious arousal

52.18 (13.75)

51.73 (12.95)

10

.252

.806

.079

Depression

53.64 (8.93)

52.09 (9.86)

10

.765

.462

.235

Anger/irritability

54.09 (10.36)

51.73 (10.52)

10

.992

.345

.299

Intrusive experiences

58.91 (13.13)

57.09 (15.62)

10

.995

.343

.300

Defensive avoidance

59.36 (12.48)

58.82 (12.03)

10

.367

.721

.115

Dissociation

53.45 (10.23)

56.73 (11.70)

10

-1.121

.289

.334

Sexual concerns

55.82 (13.69)

53.36 (12.27)

10

1.155

.275

.343

Dysfunctional sexual
Behavior

63.09 (18.86)

59.64 (18.02)

10

1.026

.329

.309

Impaired self-reference

59.00 (12.01)

56.82 (10.74)

10

.976

.352

.295

Tension reduction
behavior
p < .05

61.36 (13.31)

58.36 (14.09)

10

.974

.353

.294

Independent t tests were lastly conducted to compare posttest OQ-45.2 and TSI scores for
both the art therapy and control groups to determine if group changes were significantly different
(Tables 7 and 8). Since significant reductions in scores were observed with the OQ-45.2 data
comparing pretest and posttest results in the art therapy group evaluations with no significant
reductions with control group data, it was suspected that posttest OQ-45.2 scores comparing art
therapy and control groups might indicate significant changes in this test comparison. However,
neither the individual scale scores nor the total score of the OQ-45.2 indicated significant
differences between art therapy and control group variances (Table 7), establishing the

62

assumption of homogeneity of variances between the posttest results of the art therapy and
control groups.
Table 7. OQ-45.2 Scores for Art Therapy and Control Groups at Posttest.

OQ Score

Symptom
distress

Interpersonal
relations

Group

Art therapy

31.00 (12.85)

Control

31.91 (18.23)

Art therapy

16.69 (5.62)

Control

14.91 (7.61)

Art therapy

10.46 (4.31)

Social role
performance Control

Total score

M SD

Art therapy
Control

df

significance

22

-.143

.888

.030

22

.660

.513

.139

22

-.823

.419

.173

22

-.109

.914

.023

12.09 (5.39)
57.69 (22.06)
58.82 (28.68)

p < .05

Similarly, the independent t test conducted on data from the TSI posttest comparisons of
the art therapy and control groups resulted in no statistically significant findings on any of the ten
TSI scales (Table 8). Effect size in these analyses was generally small. However, Levenes test
for equality of variances indicated that scores for the IE and the DSB scales of the TSI were
significant (p =.001 and p =.047 respectively) therefore equal variances could not be assumed

63

for these two scales. Therefore, Table 8 reports M, SD, df, t, significance and r for the alternate
hypothesis for the IE and DSB scales. The assumption of homogeneity of variances was tenable
for the remaining eight scales of the TSI.
Table 8. TSI Scores for Art Therapy and Control Groups at Posttest

TSI Scale

Group

M SD

Art therapy

50.17 (8.91)

Control

51.73 (12.95)

Art therapy

52.07 (7.48)

Control

52.09 (9.86)

Art therapy

53.36 (11.12)

Control

51.73 (10.52)

Art therapy

58.29 (7.69)

Control

57.09 (15.62)

Art therapy

60.29 (10.08)

Control

58.82 (12.03)

Art therapy

54.71 (10.92)

Control

56.73 (11.70)

Anxious arousal

Depression

Anger/irritability

Intrusive
experiences 1

Defensive
avoidance

Dissociation

Sexual concerns

Art therapy
Control

52.00 (7.57)
53.36 (12.27)

64

df

significance

23

-.379

.709

.078

23

-.006

.996

.001

23

.372

.713

.077

14

.232

.820

.048

23

.332

.743

.069

23

-.443

.662

.092

23

-.342

.735

.071

TSI Scale

Dysfunctional
sexual behavior 1

Impaired selfreference

Tension reduction
behavior

Group

M SD

Art therapy

58.64 (9.66)

Control

59.64 (18.01)

Art therapy

53.14 (8.71)

Control

56.82 (10.74)

Art therapy

56.57 (9.98)

Control

58.36 (14.09)

df

significance

15

-.165

.871

.043

23

-.946

.354

.194

23

-.372

.713

.077

p < .05
1
Levenes test for
equal variances
not assumed p <
.05

Statistical Analysis: MANOVA

The use of multiple t tests on individual data sets is known to allow for increases in Type
1 errors, or errors which indicate significance even when no significance exists (Fields, 2005).
Consequently, the data from both the OQ-45.2 and the TSI were analyzed using multiple analysis
of variance (MANOVA) testing to correct for type 1 errors and to evaluate any interactions
between the scales within each data collection instrument. For the MANOVA analyses posttest
mean scores were subtracted from pretest mean scores of each scale in both the OQ-45.2 and the
TSI to provide a single number representing either positive or negative change in symptomology
over duration of the experiment. With the OQ-45.2 the total scale is the sum of the 3 subscales,
SD, IR and SR, and therefore was not included in the analysis.

65

The results of the MANOVA on the OQ-45.2 data indicated no significant differences (F
= .255, p = .857, df = 3, 19) in the improvement of the OQ-45.2 scores between the art therapy
and control groups. No significant changes were observed in the SD scale (F =.606, p =.445, df
=1), the IR scale (F =.001, p =.978, df =1) and the SR scale (F =.055, p =.817, df =1). No
interactions were observed in the OQ-45.2 data set. Similarly, results of the MANOVA of the
TSI posttest changes were not significant (F =.432, p =.905, df =10, 13). Further, no significance
was observed in the AA scale (F =.214, p =.648, df =1), D scale (F =.060, p =.809, df =1), AI
scale (F =.034, p =.856, df =1), IE scale (F =.037, p =.849, df =1), DA scale (F =.196, p =.662,
df =1), DIS scale (F =2.585, p =.122, df =1), SC scale (F =.003, p =.956, df =1), DSB scale (F
=.316, p =.580, df =1), ISR scale (F =.501, p =.486, df =1) and the TRB scale (F =.026, p =.872,
df =1), nor were significant interactions observed.
Figure 2 illustrates the differences in OQ-45.2 scores between pretest and posttest mean
scores for the control and art therapy treatment group participants. As previously described for
both groups the mean posttest group scores were subtracted from the mean pretest scores.
Therefore a positive number indicates improvement in the symptomology over the course of the
experiment. The blue bars represent the control group scores, while the purple bars represent art
therapy group scores. The total bar for both control and treatment is the sum of respective group
subscale pretest scores for SD, IR and SR minus the respective group subscale posttest scores.

66

Differences Between OQ-45.2 Pretest and Posttest Scores

10
8
6
OQ-45.2 Scores

4
2
0
-2

SD

IR

SR

Total

Control

3.33

3.84

0.17

7.42

Treatment

6.31

2.77

-0.08

9.46

OQ-45.2 Subscale and Total Scores

Figure 2 Differences Between OQ-45.2 Pretest and Posttest Scores

The SD subscale shows a greater reduction in treatment group score (6.31) than
the control group score (3.33), while the IR subscale indicated a greater reduction in the control
group (3.84) compared to the treatment group (2.77). The SR subscale scores changed minimally
in either group. The total scores show a greater overall reduction in the treatment group (9.46)
compared to the control group (7.42). However, none of these changes were statistically
significant.

67

Differences Between TSI Pretest and Posttest Scores

8
6
4
TSI Scores 2
0
-2
-4
Control
Treatment

Control
AA

AI

IE

0.45

0.74

2.36

2.5

2.93

3.93

DA

DIS

SC

DSB

ISR

TRB

1.82

0.54 -3.28 2.46

3.45

2.18

2.78

1.78

6.43

4.93

2.86

2.71

TSI Scales

Control

Treatment

Figure 3 Differences Between TSI Pretest and Posttest Scores

The differences in the TSI data for control and treatment group pretest and posttest mean
scores are indicated in Figure 3. As with the OQ-45.2 data figure, the blue bars represent the
change in the control group mean scores and the purple bars represent the change in the
treatment group mean scores. With the exception of the DIS scale, which showed a negative
increase reported in this behavioral characteristic, all control scores were reduced. All TSI scale
scores were reduced in the art therapy treatment group over the treatment time period. Positive
changes in art therapy scores were greater than those in the control group. None of the
differences between pretest and posttest scores represent a statistically significant change.

68

Qualitative Results
The results of this study can be better understood qualitatively by examining client
artwork and verbal feedback during the treatment sessions. Though test results did not indicate a
statistically significant effect, observation of the treatment sessions and client responses
indicated a positive effect. Samples of client artwork along with a summary of verbal responses
can be found in Appendix G. Qualitative responses to the treatment are also contained in the post
study evaluation (Appendix F).
The questionnaire consisted of five open-ended questions that gave participants an
opportunity to give feedback about the group and their participation. Responses were extremely
positive indicating that all participants had enjoyed the experience and would recommend it to
others. When asked if the experience had been positive and how it was positive, respondents
comments included that it had reduced stress, helped them address problems, helped them to
open up and express pent up feelings. In addition, they stated that they had enjoyed the
opportunity to use art materials and talk to each other. When asked what they did not like about
the program, the majority answered Nothing. Some responded that it had been difficult to talk
about their drawings at first, but realized that it was helpful. When asked if they would
recommend the group to others, and why, all responses were affirmative. When asked if the
experience had helped them to address unpleasant past experiences 76% responded yes. The
most frequent suggestions for improvement of the program was to make the treatment sessions
longer and continue them for a longer period of time. Group participants felt that they would
benefit from continued participation in art therapy treatment.

69

Summary of Findings
A sample of 50 incarcerated women participated in art therapy groups to study the effect
of treatment on psychological outcome scores. Of the original 50 women, 26 completed the
study. The Outcome Questionnaire (OQ-45.2) and the Trauma Symptom Inventory (TSI) were
completed before starting treatment and at the conclusion of the treatment period. Initial scores
from both groups were used to determine equality of variance. Initial scores from each group
with each instrument were compared to post scores using a paired sample t test procedure. A
MANOVA was conducted to analyze interactions between subscores. Control group scores did
not change significantly during the test period for either instrument. Art therapy group scores
improved significantly on the SD scale and the total score of the OQ-45.2 and approached
significance on the IR subscale. TSI results were significantly different on the ISR scale and
approached significance on the IE and DSB scales. An independent t test was used to compare
posttest scores. Changes in posttest scores were not significantly different among groups.
MANOVA analysis was not significant for either instrument. Qualitative information was
helpful in understanding the clinical effects of the treatment, and added perspective to the scope
of the study.

70

CHAPTER FIVE: CONCLUSIONS

This study was designed to evaluate the effectiveness of group art therapy treatment in
decreasing symptoms of trauma and psychological distress in incarcerated women. Based on
literature in art therapy and expressive writing, it was hypothesized that participants who
engaged in art exercises and then described the process in a group setting would demonstrate
reduced symptoms as evidenced by scores on the OQ-45.2 and the TSI. This chapter discusses
the empirical findings of this study and qualitative results evident in inmate responses to post
study evaluation questions and client treatment work samples. The research question posed by
this study was, Are expressive arts treatments effective in decreasing symptoms of trauma and
psychological distress in incarcerated women?
Results of this study did not provide empirical evidence that the treatment was effective
in achieving the desired effect, therefore, the null hypothesis was confirmed. Though the results
of data analysis did not indicate statistically significant changes in overall scores some
significance was found on individual treatment scales. Treatment group scores changed
significantly between pretest and post test on the SD (Symptom Distress) scale and the total
score (OQ-45.2), and the ISR (Impaired Self Reference) subscale (TSI). Scores measuring
psychological distress and trauma symptoms generally decreased over time for all study
participants, however, treatment participants scores improved at a greater rate. In addition, the
qualitative results were extremely positive and provided anecdotal evidence that art therapy may
still be a promising treatment option for incarcerated women warranting further study.

71

Limitations of the Study

Research conducted in a correctional facility comes with inherent limitations. Personnel
involved in administering the study are required to obtain security clearance and training prior to
entering the facility. Some correctional staff members view unofficial staff as outsiders and the
services they offer as counter to the purpose of incarceration. While some correctional staff were
cooperative and supportive, others perceived art therapy treatment as unnecessary and disruptive
to jail procedures and sometimes hindered the participation and success of the treatment. Their
actions, though subtle, often discouraged inmate participation. In some instances corrections
officers forced inmates to choose between attending an art therapy group or spending time
outside, an opportunity that is usually offered only once a day. Another officer searched each
individual as they left the classroom causing some individuals to withdraw from the group to
avoid the searches.
Group treatment was administered by the primary investigator who had prior experience
working with incarcerated clients and the use of art therapy. Entering a corrections facility for
the first time can be intimidating and uncomfortable (Karban & West, 1994). Because this
population is especially distrustful, it is imperative that counselors working in the corrections
environment be able to establish a strong relationship with inmates. Counselor needs to be able
to be non-judgmental and unaffected by stereotypes of arrestees. As with all counselors, it is
important for them to be empathetic and able to instill confidence while quickly develop trusting
relationships (Young , 2005). An in-depth understanding of addiction and trauma issues is also
important. The counselor also needs a basic understanding of art therapy theory and techniques.

72

Constancy in the facilitator encouraged early development in the therapeutic relationship which
facilitated participant self disclosure.
As a result of the living arrangements in the jail, sample selection was restricted. In the
jail, inmates are divided into dorms or pods of approximately 25 40 women. Correctional
policies prohibit contact between the residents of separate dorms. Consequently, groups were
formed with volunteers from a single limited pool. This resulted in small group size, and did not
allow for the random selection of group participants. These two factors necessitated the use of a
quasi-experimental design. In addition, the small group size precluded more sophisticated tests
such as MANOVA. which was conducted but yielded no significant statistical information. Thus,
one of the weaknesses of the study was the inability to utilize more sophisticated statistics.
Attrition was also a major hindrance in this study. The sample number was reduced by
nearly half as the study proceeded. Since groups were closed to new attendees due to the closed
experimental design, attrition could not be offset by the addition of new members. Some group
participants may have been eliminated from the group due to lack of communication with
corrections program staff about jail procedure prior to conducting art therapy sessions. Some
attendees were lost due to jail staff failing to place individuals names on subsequent attendance
rosters after one absence. Efforts to inform corrections staff of expectations and being thoroughly
informed in jail attendance policies ahead of time could have improved study outcomes. County
jail inmates are also more likely to move without warning. Many of them are awaiting trial and
their future is uncertain so changes happen unexpectedly leading to attrition. State and federal
prisons may provide opportunities for more individuals to complete treatment and a prison may
yield a larger population and larger participant groups.

73

According to the study design, groups were closed to new participants after the first
session. Only those who attended the first session were allowed to complete the study. Some
individuals were removed from the group roster by corrections staff members because they chose
to attend another activity held at the same time. This resulted in the group losing members even
though they had not made a decision to withdraw from the group.
Control group participants received art therapy treatment after the final data was
collected. At that time, attendance was open to any inmates who desired to attend. The group
grew from six members to fifteen, the maximum number of group attendees allowed in any
group in the facility, with additional inmates who desired to attend. This surge in attendance
indicated that inmates had shared positive attitudes about the program with others in their dorm.
This positive feedback about the art therapy groups in the dorms encouraged others to be
interested in participation. Future studies may avoid some attrition by utilizing an open group
enrollment allowing new attendees to join the group and then be monitored for a specific number
of sessions. Completion of testing instruments could be done individually at the beginning and
end of treatment or at regular intervals during the study.
Instruments
While the instruments were designed to measure psychological improvements in distress
and the severity of symptoms related to trauma, instrumentation was thought to be somewhat
limited in effectiveness with incarcerated individuals. Even though inmates were informed that
responses to the test materials would be kept confidential and would not effect inmate status in
corrections, responses appeared to be unreliable in some instances either because inmates have a
limited awareness of personal issues or are reluctant to disclose it. This may be explained by the

74

distrust inherent in the jail environment and fears that information disclosed on the measures
may be shared outside the study to influence either inmate legal standing or ongoing parental
custody proceedings. Some responses were extremely low which may indicate efforts to
minimize distress levels. Inmates may also have become bored or tired of the process before
completing the 100 questions on the TSI and may have given random answers without
considering the response. Instruments were repeated at a three week interval suggesting that
questions may have been familiar and responses repeated.
The OQ-45.2 is designed to be brief and sensitive to change, to measure client progress,
and to access common symptoms indicating emotional distress (Lambert, et al. 2004). Test
makers recommend that test-takers respond to items on the OQ-45.2 regarding work or school
according to current life activities. Scores on the SR and IR subscales were inconsistent which
may indicate that study participants were unable to relate the questions to their life in jail.
According to test creators the Social Role sub-score focuses on patient level of
dissatisfaction, conflict, distress, and inadequacy in tasks related to their employment, family
roles and leisure life. Assessment of social roles suggests that a persons intrapsychic problems
and symptoms can affect a persons ability to work, love, and play (Lambert, et al. 2004, p. 2).
It is arguable that while they are incarcerated individuals are not able to function in any of these
roles causing SR evaluation responses to be erratic.
The Interpersonal Relations (IR) subscale relates to satisfaction and problems in
interpersonal relationships (Lambert, et al. 2004). In an incarcerated setting individuals must rely
on mail and brief visits to continue primary interpersonal relationships with family, spouses, and
long-term friends, while the friends and associates in a jail system are limited in depth and

75

intimacy and complicated by the restrictions in a correctional facility. The utilization of the OQ45.2 in this study has brought to light some limitations that need to be resolved to make it
adaptable to use with incarcerated individuals.
The Trauma Symptom Inventory (TSI) is intended for use in the evaluation of acute and
chronic traumatic symptomatology, including, but not limited to the effects of rape, spouse
abuse, physical assault, combat, major accidents, and natural disasters, as well as the lasting
sequelae of childhood abuse and other early traumatic events (Briere,1995, p. 1).
The TSI was tested with general populations, clinical, university, and male and female Navy
recruits. This instrument is also designed to address specific symptoms experienced by those
who have been victims of childhood and adult interpersonal violence such as anger, depression,
dissociation, sexual problems, interpersonal difficulties, disturbance in self-functions, and acting
out behaviors such as self-mutilation and compulsive or dysfunctional sexual activity (Becker,
Skinner, Abel & Treacy, 1982; Pifalo, 2006). In addition, the TSI includes validity scales which
detect responses of those who tend to minimize or exaggerate symptomology. Though not
specifically tested with inmates, the issues addressed and the validity scales indicated positive
expectations in its use with this study. Some complications in utilizing the TSI with this
population may have resulted from the length of the instrument.
Completing the OQ-45.2 and the TSI required approximately 45 minutes. Some
participants may have hurried through their responses to test items in order to finish quickly.
Others may have found the task emotionally taxing and rushed through to avoid emotional
difficulty. Control group participants may have resented the expectation to complete the
instruments twice without receiving treatment and may not have given the test instruments full

76

attention. Some responses may also have been influenced due to the familiarity of the instrument
since the interval between testing was only three weeks.
Review of Findings
The results of data analysis did not indicate statistically significant changes in overall
scores. However, significance on some treatment scales and anecdotal evidence indicate that art
therapy may still be a promising treatment option for incarcerated women. Psychological distress
and trauma symptoms generally decreased over time for treatment participants. While scores
reduced in control group members as well, greater changes took place in treatment group scores.
Several factors may have contributed to the lack of statistical significance in the final comparison
of scores. Three weeks, though longer than some treatments used in earlier studies, may not have
been long enough to allow for the phenomenon that scores drop early in treatment and then
increase as the therapy proceeds (Gussak, 2006). A longer duration of treatment may have
achieved more change because the therapeutic movement seemed to be going in the desired
direction. Though his population was markedly different, Gussak (2007) found significant
changes in BDI II (Beck Depression Inventory) scores in a similar study with male inmates in a
psychiatric treatment program after eight sessions of art therapy. The sample size was
comparable with this study (N=27) and results were mixed with the BDI II yielding significant
change in scores.
Though study participants were informed that results from the measures would not be
shared with correction personnel, inmates who are often reluctant to trust may have given
inaccurate answers for several reasons. Study participants, many who had not yet been to trial,
may have purposely elevated responses out of fear that confidentiality may be broken and that

77

information might be used to complicate judicial or child custody outcomes. Bradley & Devino
(2007) found a high level of resilience among incarcerated women, which may also result in
minimized reports of distress. Coping mechanisms such as denial, lies, and dissociation, common
among incarcerated women, would also contribute to the tendency for inaccurate responses to
test items.
Scores for both the treatment group and control group improved, though not at significant
levels, over the treatment period, with the treatment group producing the largest changes on most
of the scales tested (Figures 2 & 3). Improvement in control group scores may be explained
by the phenomenon that though a jail environment is not pleasant, it may offer a curative
atmosphere compared with real life challenges. It is secure and all basic needs are provided
through the system. While outside, women see themselves as caretakers and providers struggling
with responsibilities and stressors. While in custody, at least short term solutions have been
implemented to solve concerns even though they may not be to the satisfaction of the inmate.
Female detainees have little responsibility other than complying with correction staff directives,
and many take advantage of forced opportunities to rest, read, exercise, and participate in jail
programming, which includes attendance of psychoeducational groups, twelve-step support
groups and church meetings. Some inmates see jail as a refuge, and after repeated arrests, they
become familiar with the expectations and view it as an opportunity to escape the everyday cares
of stressful lives.
While the overall hypothesis was not supported in this study, results of the statistical
analysis on scores from the OQ-45.2 identified several statistically significant changes between
pre and post scores. The OQ-45.2 scores for art therapy treatment group subjects for symptom

78

distress (p =.044) and the overall total score (p =.038) were lowered significantly. The
Interpersonal Relations sub score approached significance (p =.051).while Social Role
Performance did not change significantly. Scores for the control group were not significantly
changed on any scale. Treatment and control scores reduced over the three week treatment
period in total scores and Symptom distress scores, with the largest changes occurring in the
treatment group. Treatment and control scores for Interpersonal Relations (IR) were reduced
with the larger change occurring in the control group. Scores for Social Role Performance
control group scores were reduced slightly, while the treatment group had a slight increase
(Figure 2). Scores on the Interpersonal Relationship (IR), and Social Role Performance (SR)
scales were not consistent. The IR subscale assesses such complaints as loneliness, conflict with
others and marriage and family difficulties (Lambert, et al. 2004, p.29). Inmates are likely to
view loneliness and conflict with others as the norm for incarceration while relationships with
family and significant others are put on hold or limited to brief contacts, making it difficult to
make an accurate assessment on these items. The SR subscale measures the extent to which
difficulties fulfilling workplace, student or home duties are present. Conflicts at work, overwork,
distress and inefficiency in these roles are assessed (Lambert, et al. 2004, p. 29) Written
instructions on the instrument direct test takers to Look back over the last weekmark the box
under the category which best describes your current situation. For this questionnaire, work is
defined as employment, school, housework, volunteer work, and so forth (Lambert, et al. 2004,
p. 63). Study participants may not have been able to make the connection between these
questionnaire items and incarceration.

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The Trauma Symptom Inventory (TSI) was designed to measure the extent to which
respondents experience specific symptoms of trauma. Data analysis found significant changes in
the ISR (Impaired Self Reference) scale (p = .044) and approached significance with the IE
(Intrusive Experiences) scale (p = .083) and the DSB (Dysfunctional Sexual Behavior) scale
(p=.090) for art therapy treatment group participants. Changes were not significant in TSI scores
for control group participants.
Mean scores for the TSI for both the control group and the treatment group were lower at
posttest, however greater changes appear in the treatment group with one exception. The scores
in the DIS (Dissociation) scale increased for control group participants at a higher rate than
scores for the treatment group decreased (Figure 2). Statistical analysis did not indicate that the
changes in scores were significant between pre and posttest applications.
Treatment Procedures
In the initial discussion, clients were told that their artwork would not be evaluated
according to artistic merit and that they should not worry about drawing skill. The emphasis was
placed on thinking and feeling. Apologies for drawing ability no longer occurred after the first
session and with a few exceptions, drawings were openly shared with the group. As participants
talked about their work, disclosure was usually kept at appropriate levels. Because of the
intensity of feelings evoked through expressive arts, it is important for the facilitator to conduct
the verbal portion of the session with some attention to limiting client responses to a comfortable
level. There is a tendency to over disclose, resulting in the participant withdrawing in future
discussions or in withdrawal from the group. This may be especially applicable in a jail setting.

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Six art therapy exercises were designed for use in the study (Appendix D). In this section,
each will be evaluated based on their perceived effectiveness in the treatment groups. Samples of
treatment work and client responses will be provided. Descriptions, administration format, and
treatment work samples of the exercises can be found in Appendix D. The first two exercises
focused on the development of the therapeutic relationship and group cohesion and required a
limited amount of self-disclosure. Exercises increased in intensity and depth as the study
progressed. The final exercise was intended to leave group members with a positive outlook and
insight into their future, confidence in their ability to change, and a new life perspective. Results
were not always consistent with the plan and required some alteration in the exercise protocols.
However, each exercise stimulated group members to self disclose and participate in the
therapeutic process.
Exercise one, My happily ever after, was easy and comfortable for study participants to
complete. It helped to allay client discomfort with drawing ability, allowed for a playful
atmosphere and reduced resistance to disclosure. Two themes emerged in this exercise. The first
was a happy home with family and basic comforts such as a car and adequate money (Figure 4).
This theme was evident in the majority of the drawings. The second theme was less prevalent,
but did appear in a few drawings. Participants viewed the theme from a spiritual perspective,
indicating a relationship with a higher power or a peaceful afterlife existence At the conclusion
of the exercise, participants recognized that they shared many of the same dreams and goals
because their drawings and verbal descriptions shared the same themes. As a result, participants
recognized that their feelings were shared by everyone. Group members became aware of

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common experiences and feelings and contributed to the development of group cohesion and
aided participants to overcome part of the distrust and resistance in the group.

Figure 4 Happily Ever After.

This drawing was done by a woman who had recently lost her significant other to a drug
overdose. She saw happiness as including a place of her own with a child, animals, nature, and a
significant other.
Exercise two titled Masks required introspection, deeper thought, and increased selfdisclosure. This exercise was effective in helping participants discuss personal coping styles and
evaluating their effectiveness in dealing with problems. Visual and verbal responses identified
commonalities among group members and strengthened group cohesion. One theme that
emerged was a mask of unconcern and over happiness, or flat affect. Most group members stated
that they hid real emotion behind a mask of apathy or confidence. Others identified masks of
of anger and aggression that they used to deal with or hide problems.

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Figure

Figure 5. Masks A.
The mask on the left was described as free as a bird. The artist explained that this is the
face she uses to give others the impression that everything is fine and that she doesnt have any
cares. She described the mask on the right as being one of glamour, but explained that it isnt
really pretty and doesnt really work.

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Figure 6. Masks B.
The mask on the left is described as being beautiful and glamorous. The figure is dressed
as an exotic dancer. The face on the right illustrates the mask she wears when things are not
going her way and she wants to get things done.
Exercise three, The child within, was based on Bradshaws (1988) concept of shamebased upbringing. This exercise concept was difficult to explain and participants found it
difficult to conceptualize. Drawings included thoughts and ideas related to their own parents
rather than the parent voice in their thinking. The adult voice was ignored in the drawings. It was
necessary to alter this exercise to fit group needs. Instead, inmates participated in a guided
imagery where they pictured themselves as a child and were directed to identify some specific
upsetting experience they had during that time. Then they were asked to illustrate it. Some
illustrated abandonment or abuse. Though quite different from the original concept, this change
facilitated deep disclosure about personal feelings of inadequacy and unresolved issues with

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parents and difficult times encountered while growing up and helped them to identify areas
where they still experienced negative feelings from childhood. The original exercise proved to be
too complex for this group but might be effective after the group had met together for a longer
period of time and had established a broader understanding of personal issues.

Figure 7. The Child Within

This inmate spent her childhood in facilities for orphans and was placed there by her
parents. She described the feelings of waiting there with the hope that she would someday be
adopted, and the experience of watching others, including her own siblings, go to homes and
families who wanted them.
Exercise four, Monsters, proved to be enjoyable and effective. Inmate responses were
insightful with appropriate disclosure. Their work illustrated a variety of causes for fear and
powerlessness and included addictions, personal weaknesses, specific individuals and living
situations. This exercise was powerful and required deep introspection and disclosure. The

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discussion included humor and group cohesion was strengthened as participants recognized
common experiences. Themes that emerged included drugs and other addictive substances,
powerful people, and jail. This exercise was very effective for all group participants.

Figure 8. Monsters A.
This inmate included her home and her children in the picture. She said that there was a
lot of clouds and storms in her life, and that she was her own monster.

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Figure 9. Monsters B.
The inmate who drew this first illustrated a green hairy creature. She took more paper and
began to draw this indicating that her addiction was her monster.
Exercise five, My most upsetting experience, was adapted from James Pennebakers
therapeutic writing study (Pennebaker, 1990). However, when the topic was introduced in the
first session it was overwhelming to study participants. To choose the most upsetting experience
was, in itself, traumatic due to the severity and frequency of difficult events in the lives of female
inmates. Instructions were modified to identify traumatic experiences during childhood which
reduced the time in this exercise involved and made the task manageable. This resulted in
illustrations of abandonment, abuse, loneliness, helplessness and trauma. The exercise in its
original form required a mental review of a lifetime of upsetting experiences, requiring more
emotional strength than group members could expend. Because these women had experienced

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many and severe upsetting experiences it was necessary to reduce the exercise in size by limiting
time period.

Figure 10. My Most Upsetting Experience A.

The artist described being in her backyard hanging out clothes when a friend came into
the yard and was shot by a policeman. She described how the day had been beautiful and she was
enjoying the weather when the incident happened.

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Figure 11. My Most Upsetting Experience B.

This inmate chose an incident from her childhood. She said that this was the day her Dad
left. She was 8 year old when it happened.
Exercise six, Lost and Found, was designed to help participants identify what they had
lost due to trauma and to recognize positives and strengths they may have gained from
experience. This exercise encouraged prisoners to recognize losses and consequences of
experiences and personal choices. Each also identified strengths and positive outcomes they had
gained. This exercise was effective in helping to bring closure to the art therapy group and instill
confidence and courage to change in the thoughts of participants. Inmates knew that this would
be the last session, disclosure was limited, and the exercise did not evoke the same depth of
thought as earlier ones.

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Figure 12. Lost and Found.

On the left, the participant said that everything she had ever had went up in flames. She
said that she had gained money power and respect but that they had all been lost. She felt that she
had gained and retained power and strength. In each of this individuals drawing she wrote the
words Its a thin line between love and hate.
The most successful art exercises were directive. They were designed with a specific
outcome in mind such as the masks or monsters.. These exercises allowed for a use of humor and
they evoked common responses to shared experiences. For example, the closing discussion in
session four, Monsters, included a discussion about fear of the dark, and a discussion about
addiction and jail and how the individuals felt they were caught and couldnt explain how they
got there. Non directive exercises were less effective. These exercises gave a lot of freedom in
the drawing subject and may have placed too much responsibility and discomfort on the
participant for beginning clients. A good example of this was the response to exercise 5, the child

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within, participants responded with confusion, there was little interaction during the drawing
portion of the group and participants had difficulty determining what they wanted to draw. When
the drawing exercise was altered, participants were able to identify something they wanted to
share.
Materials used in the group were appropriate from a corrections facility standpoint and
also contributed to the success of the study. Study participants were not confident in their ability
to draw and were comfortable with the drawing materials used. Inmates were issued both
markers and crayons. Many were more comfortable with crayons and were given the option of
folding the paper to reduce size when desired.
These drawings illustrate the effectiveness of the art therapy medium in helping clients
identify and address difficult experiences. Some were able to take advantage of the opportunity
to identify and address life-changing issues and begin to make those changes. Some of the
drawings were not very illustrative or remarkable to look at, however, the verbal descriptions and
responses indicated that experience had sparked some deeper thinking and emotional awareness.
Qualitative Results
Questions on the post study evaluation indicated the feelings of participants about their
experiences in the study. Participant responses were overwhelmingly positive. The most frequent
suggestion for improving the program was to lengthen group sessions and extend the study. The
majority of participants responded warmly and positively to the art exercises and produced
effective therapeutic work and open verbal responses. The inmates indicated that they enjoyed
the experience and would recommend the program to others. They also felt that the experience
had been positive and had helped them to address issues from their pasts.

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The post study evaluation questionnaire (Appendix F) consisted of five open-ended

questions. In response to question one: How was this experience enjoyable for you? One
individual responded, It has helped me cope with my problems here and in the past. It also has
made me feel loved and wanted when I thought I wasnt. I have truly been inspired by this
program. Drawing makes me relieve a lot of stress. Another stated, I like putting my thoughts
and feelings on paper and actually seeing them. A third added, it made me feel like I can
talk about my problems in life instead of keeping them inside of me.
Question two What was there bout this experience that you did not like? received a
similar response. The majority of participants stated that there was not anything they disliked
about the program. Some expressed some misgivings about disclosure, for example, At first I
didnt like talking about our pictures in front of everyone, but now I am okay. Another said, I
didnt like having to talk about some experiences but it was helpful to do so.
Question three asked Would you recommend this group to others? Why or why not?
Every inmate responded yes. Their reasons included, art lets us get into our inner minds
and brings out more of what is inside of us. Another said, Yes, because this group can help you
take a lot of things off your mind and ease a lot of pain. A third stated, Yes, it helps to get
things out. It helps you have an understanding about your life and you wont have to be
ashamed.
Question four asked Did this experience help you to address unpleasant experiences
from your past? Over two thirds of the participants answered yes. Their explanations
included, The projects were just right, every drawing released some of my anger and sadness.
Another responded, Yes, it let me express or release what has happened, what bothers me, and

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recent tragedies in my life on paper so I could know what they were, then I felt much better and
could deal with them in my mind. A third said, Yes, because I never knew I could tell anyone
how I felt because I never. Nobody could never listen. Those who answered No shared these
reasons: We werent expected to say much. Another said, Not really, theyre still there but
knowing I could still bring them to the surface.
Question five invited additional comments and suggestions. The most frequent comment
was a suggestion that groups would be better if they were longer, more frequent, and continuous.
Some comments of interest included, It will help a lot of women who have no way of letting go
of things. This way is better, through art. Another commented, I loved the class. I think you
should maybe focus more on specifics (the assignments sometimes left too much up to us) or
maybe have some writing assignments. Many express appreciation for the opportunity to
participate and a hope that the treatment can be continued.
Recommendations for Future Research and Implications
Further research utilizing art therapy and other expressive arts therapies with incarcerated
individuals are needed. Current literature is filled with positive applications of art therapy with a
wide range of populations and diagnoses but is generally anecdotal (e.g. Eisdell, 2005; Samuels,
1994; Ulman, 1992;). Because it is so versatile, little specific, empirical research has been
conducted. Gladding (2005) identified a dearth of research involving creative arts therapies
while, at the same time, acknowledging the difficulty in conducting research in this arena. If the
creative arts in counseling are to be uniformly respected, they must merit appreciation based on
more than anecdotal testimony (Gladding, 2005, p. 192). There are many opportunities to

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compare the effectiveness of expressive arts techniques with each other and used in
combinations, as well as making comparisons with established therapeutic practices
Outcome measures specifically developed for incarcerated women and the problems they
face would improve the ability to assess treatment effectiveness with improved accuracy and
contribute to accurate diagnosis and treatment of serious mental health problems (Henriquez,
2002). Studies specific to pathologies such as DID, personality disorders, substance abuse, and
trauma would make may provide valuable information to mental health professions who work
with this group.
Future research in utilizing group art therapy offers several advantages to the corrections
community. Group art therapy could relieve some of overwhelming treatment loads faced by
mental health professionals currently working in jail facilities. A better understanding of inmate
issues would benefit corrections programs in identifying and treating inmates more efficiently
and effectively. Improvement in the delivery of treatment could facilitate a drop in disciplinary
problems during incarceration and may lead to successful prisoner transitions back into society.
Ultimately, the cycle of arrests and recidivism may be reduced benefiting individuals, families,
and society.
Work in correctional facilities may be improved with the development of training
programs for security, mental health and substance abuse professionals, correctional and
treatment staff. Training programs need to be developed to educate staff to understand specific
issues of female detainees and treatment interventions designed to affect women diagnosed
mental illness in jails (Henriquez, 2002). From a corrections perspective, implementing
expressive arts therapies with female inmates could result in improved inmate behavior and

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reduced recidivism while providing much needed treatment to inmates at a reduced time demand
for mental health professionals and at a lower cost.
Creativity is an important element of counseling. Developing or practicing counseling
professionals would benefit from increased education and personal confidence in utilizing
expressive arts techniques. (Carson & Becker, 2004). Students would gain valuable practical
experience through participation in experiential workshops and classes, where they would have
opportunities to experience the potential power of expressive techniques and learn to integrate
them into their work with clients. Students could improve counseling capabilities through
exposure to treatment of incarcerated individuals through internships, group facilitation and
research involvement with this population.
Future research should examine the effects of art therapy in a group setting. Interaction in
the group is an important factor in the favorable implications of this study. Though this study
provided limited statistical significance, feedback from participants suggest that it was clinically
significant. Art therapy conducted with groups offers an economical, efficient treatment medium
that may capacitate treatment for women who currently receive little treatment in jail, helping
them to cope with prison life and difficulties in their lives after release. Incarceration for women
has a far reaching influence with individuals, children, families and communities. Finding
effective treatment for incarcerated women would be a boon to them and to society in general
As stated earlier, this study has several limitations. The sample size was greatly reduced
through attrition. The instruments used were limited in their application to incarcerated women.
The desired empirical evidence was not produced in this study. However, the qualitative
information indicated that the treatment was effective, and that those who participated in the

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study felt a positive result. The challenge for future research may be to find ways to establish
empirical evidence to match the overwhelming anecdotal evidence.

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APPENDIX A: IRB APPROVAL

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APPENDIX B: RECRUITMENT FLYER

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Art Therapy Treatments with Incarcerated Women.

This is an invitation to participate in a research study:
You are being invited to take part in a research study which will include about 45 people. To
participate in this study you must be 18 years of age or older and be a female inmate in the John
E. Polk Correctional Facility in Seminole County Florida.
This study will be conducted by Bonnie J. Erickson, a doctoral student in the College of
Education and the Department of Child, Family & Community Sciences at the University of
Central Florida. This research is being supervised by Mark E. Young, PhD, a UCF faculty
supervisor in Counselor Education. For more information, contact Mr. Joseph J. Acton, Program
Coordinator, or call 407-823-3063 (UCF, department of counselor education) or write P.O. Box
161250, University of Central Florida, Orlando, Florida 32816.
Purpose of the study: The purpose of this study is to study the effectiveness of art therapy in
helping female inmates express and cope with upsetting memories and traumas from their pasts.
What you will be asked to do in the study: Volunteers will be asked to complete three
questionnaires before and after the group sessions. Participants will participate in six treatment
sessions over a period of three weeks using art therapy to explore and process personal
experiences involving upsetting feelings and trauma.
Time required: The study will require two one hour sessions, held weekly for three weeks for a
total of six sessions. Volunteers will also be invited to attend a one hour introductory
presentation about the study.
Compensation or payment:
In accordance with Seminole County Corrections policy, inmates will not receive compensation
of any sort for their involvement in this research. At the conclusion of the study, all treatment
work produced in the sessions, whether art or writing will be returned to study participants.
Inmates will not receive negative consequences for deciding not to be involved with this study.

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APPENDIX C: INFORMED CONSENT

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Informed Consent
Researchers at the University of Central Florida (UCF) study many topics. To do this we need
the help of people who agree to take part in a research study. You are being invited to take part
in a research study which will include about 45 people. You can ask questions about the
research. You can read this form and agree to take part right now, or take the form with you to
study before you decide. You will be told if any new information is learned which may affect
your willingness to continue taking part in this study. You have been asked to take part in this
research study because you are woman and an inmate. You must be 18 years of age or older to be
included in the research study and sign this form.
Study title: Art Therapy Treatment with Incarcerated Women.
This study will be conducted by Bonnie J. Erickson, a doctoral student in the College of
Education and the Department of Child, Family & Community Sciences at the University of
Central Florida. This research is being supervised by Mark E. Young, PhD, a UCF faculty
supervisor in Counselor Education
Purpose of the research study: The purpose of this study is to explore the effectiveness of art
therapy in helping female inmates express and cope with upsetting memories and traumas from
their pasts.
What you will be asked to do in the study: Volunteers will be asked to complete pre-test and
post-test evaluations and a demographic questionnaire. Participants will participate in six
treatment sessions over a period of three weeks which involve drawing activities about personal
experiences involving upsetting feelings and trauma.
Voluntary participation: You should take part in this study only because you want to. There is
no penalty for not taking part, and you will not lose any benefits. You have the right to stop at
any time. Just tell the researcher that you want to stop. You will be told if any new information
is learned which may affect your willingness to continue taking part in this study.
Location: The study will be conducted in the Lake County Corrections Facility in Lake County
Florida.

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Time required: The study will require two one hour sessions, held weekly for three weeks for a
total of six sessions. Volunteers will also be invited to attend a one hour introductory
presentation about the study.
Audio or video taping: You will not be audio or video taped by the researcher.
Risks: It is possible that participation in this study may bring up unpleasant memories of past
experiences. Mental Health Services are available on site through the mental health staff at the
Lake County Correctional Facility. In addition, the primary researcher is a Licensed Mental
Health Counselor and will conduct all research sessions.
There are no expected risks for taking part in this study. You do not have to answer every
question or complete every task. You will not lose any benefits if you skip questions or tasks.
You do not have to answer any questions that make you feel uncomfortable.
Confidentiality: Every effort will be made to protect confidentiality, however, in a group
treatment setting, confidentiality cannot be guaranteed. The researcher will make every effort to
prevent anyone not on the research team from examining treatment work and will not discuss
information shared in the group with others. Your identity will be kept confidential; you will be
given a confidential identification number to label your work. A list of names and numbers will
be kept in a different place in a password protected computer file. When the data is done and the
data have been analyzed, this list will be destroyed. Your information will be combined with
information from other people who took part in this study. When the researcher writes about this
study to share what was learned with other researchers, she will write about this combined
information. Your name will not be used in any report, so people will not know how you
answered or what you did.
Exceptions to Confidentiality: There are times when the researcher may have to show your
information to other people. For example, the law may require the researcher to show your
information to a court or to tell authorities if the researcher believes you have abused a child, are
in danger to yourself or to someone else, or disclose information about an undisclosed crime.
The researcher may have to show your identity to people who check to be sure the research was
done right. These may be people from the University of Central Florida or state, federal or local
agencies or others who pay to have the research done.
Benefits: Participation may provide a better understanding of the effects of traumatic
experiences, and provide therapeutic benefit through the use of expressive art treatments.
Participants may gain personal insight into personal experiences and reduce the negative results
of past upsetting experiences. In addition, participants may learn more about how research is
conducted.

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Additional Benefits: This study may provide good treatment options for women who are
incarcerated.
Compensation or payment:
In accordance with Lake County Corrections policy, inmates will not receive compensation of
any sort for their involvement in this research. At the conclusion of the study, all treatment work
produced in the sessions will be returned to study participants if possible. Inmates will not
receive negative consequences for deciding not to be involved with this study.
Study contact for questions about the study or to report a problem: If you have questions,
please address them to Bonnie J. Erickson, Doctoral Candidate, Counselor Education Program,
Department of Child, Family and Community Sciences in the College of Education. Additional
questions can be directed to Bonnie Erickson or Dr. Mark E. Young, Faculty Supervisor,
Department of Counselor Education at the University of Central Florida.
IRB contact about your rights in the study or to report a complaint:
Research at the
University of Central Florida involving human participants is carried out under the oversight of
the Institutional Review Board (UCF IRB). For information about the rights of people who take
part in research, please contact: Institutional Review Board, University of Central Florida, Office
of Research & Commercialization, 12201 Research Parkway, Suite 501, Orlando, FL 328263246 or by telephone at (407) 823-2901.
How to return this consent form to the researcher: Please sign and return this consent form
to Bonnie J. Erickson. By signing this letter, you give me permission to report your responses
anonymously in the final manuscript to be submitted to my faculty supervisor as part of my
course work
I have read the procedure described above
I voluntarily agree to take part in the procedure
I am at least 18 years of age or older
___________________________

__________________________

Signature of participant

Printed name of participant

____________________________________

____________

Principal Investigator

Date

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________
Date

APPENDIX D: ART THERAPY TREATMENT EXERCISES

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Group Format
Six exercises were chosen for use in the study. The exercises are outlined in the
following pages. Each exercise provides areas of focus for the session, experiential exercises,
and suggested follow up questions to be discussed as a group. Each session begins with a 10-15
minute discussion to introduce the exercise topic. During the next 30 minutes, participants
compose drawings illustrating their thoughts and feelings. The last 15 minutes participants form
a circle away from the tables and share their drawings and feelings with the group.
Materials
Materials for treatment work will be provided by the primary investigator and will be
stored in a cabinet provided inside the correctional facility. Art materials will consist of pencils
with erasers, water-based markers, crayons, and 11x18 drawing paper.

Intervention: My Happily Ever After

Objectives
Clients will identify elements in their lives that they want to eliminate, and the absence of
elements they want to include. Clients will visualize possible changes in their lives when the effects of
trauma are dealt with. Clients will experience hope for the future.
Procedure:
Step 1: Group Discussion
Direct clients to visualize a life without the present difficulties they are experiencing. Encourage
a realistic view of possibilities for the future. Discuss the areas of life that may change as progress and

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growth are achieved. Some of these might include: social, physical, financial, relationship issues,
education, behavioral changes, and emotional changes.
Step 2: Experiential Exercise
Clients will illustrate what they hope their lives might look like after they have dealt with some
of the present difficulties in their lives. Ask them to identify how far in the future this will be.
Step 3: Processing
Invite clients to share thoughts, feelings, and insights relative to this exercise. The process
questions below can be used to help clients express more about their work.
1. How far in the future is this place?
2. What barriers will you need to remove to get to this place?
3. Are you making progress to get there now?
4. What will it be like for you to be there?

Intervention: Masks
Objectives
Clients will gain an understanding of the images they project and how this relates to interactions
with others. In a discussion, clients evaluate these images to determine if they have a positive or
negative effect on their progress towards therapeutic goals. Finally, clients will translate their inner
thoughts and feelings to words as they discuss their work.
Procedure
Step 1: Group Discussion.

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The facilitator conducts a discussion about defense mechanisms and involves the clients in a
discussion about the masks that people hide behind. Examples and ideas about why we do this are
recorded on a board or flip chart. Clients are then asked to describe their own defense mechanisms and
those they have observed in others. Related terms are defined including, attitudes, facades,
stereotypes and poses. In the discussion, clients identify a variety of masks, such as confidence,
strength, invincibility, sexuality, being dangerous and unapproachable, vulnerability and dependence,
among many others. Discussion includes the positive and negative effects of the use of these masks.
Step 2: Experiential Activity. Clients are asked to identify and draw the masks they have
identified for themselves. They are not limited to one mask but are encouraged to identify as many of
their personal masks as possible, including a combination of one or more.
Step 3: Processing.
Clients assemble away from tables in a group to process the exercise. Clients are encouraged to
share the feelings and thoughts they experienced during this exercise. To alleviate feelings of
inadequacy, it is important to stress the fact that this exercise is not about creating great art, but about
the process of thinking and gaining personal insight. Ideas about strategies to eliminate, replace, or alter
dysfunctional behaviors are discussed.
The process questions below can be used to help clients express more about their work:
1. How does your mask help you and how does it hinder you?
2. Do you remember when you first started to use this mask?
3. What does the mask conceal?
4. Did you experience any surprises in doing this activity?

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Intervention: The Child Within

Objectives:
Clients will identify the child, adult, and parent roles in their thoughts and feelings. Clients will
evaluate the origin and strength of each. Clients will gain insight into their origins and their ability to
make choices.
Procedure:
Step 1: Group Discussion
Discuss the concept of the child, adult, and parent roles in our thinking. The parent voice is
often identified through thinking scripts that use should. It may also be negative self-statements. This
is an internal parent, not necessarily the actual parent. The child voice is motivated by emotion rather
than thought and often indicates decisions made as a reaction to others influences, whether real or
imagined. The adult is the thinking that leads to individual conscious choices. Discuss the origins of
ideas, values, and scripts. Discuss the differences in perspective of childhood and adulthood.
Step 2: Experiential Exercise
Clients will draw the three roles of parent, child, and adult in their lives. Encourage clients to
determine the proportion of each role, and what choices they may have made in the past relative to each
role.
Step 3: Processing
Invite clients to share thoughts, feelings, and insights relative to this exercise. The process
questions below can be used to help clients express more about their work.
1. After learning about these roles in your thinking, how would you like to change them?
2. What would you need to do to make the changes?

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3. Can you identify positive self-statements that may counteract negative self-talk.

Intervention: Monsters
Objectives
Clients will identify their worst fear and thoughts and feelings related to it. Fears will be
normalized and externalized. Coping strategies for dealing with fear will be identified.
Procedure
Step 1: Group Discussion.
Conduct a group discussion to develop a definition of what a monster is. The discussion may
include: something that is unidentifiable, scary, may harm you, usually large in size, invokes
fear, and are sometimes irrational. A personal monster may include problems that are perceived
to be monumental, and are too large or too difficult to deal with or control.

Step 2: Experiential Exercise:

Clients are to identify, and illustrate their own personal monster, or monsters. Examples
may be a self-defeating behavior, anger, addiction, dissociation, domestic violence, eating
disorders, or a past or present abuser or anything that client identifies.
Step 3: Processing
Invite clients to share thoughts, feelings, and insights relative to this exercise. The process
questions below can be used to help clients express more about their work.
1. Does identifying the monster make it a little less intimidating?
2. Does it help to know that the same monster belongs to others?
3. Is your perspective realistic?
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4. How do you work to shrink the monster down?

Intervention: My Most Upsetting Experience

Objectives:
Clients will identify specific experiences that were the most upsetting. Clients will express
feelings and thoughts related to the trauma.
Procedure:
Step 1: Group Discussion
Discuss trauma and the physical and psychological effects it creates. Discuss the importance of
identifying and expressing emotions related to trauma. Traumatic memories include emotions, visual
and sensory impressions such as smells and tactile sensations that make expression difficult.
Step 2: Experiential Exercise
Clients are directed to identify one traumatic experience that was particularly upsetting to them.
As they illustrate this experience, they are asked to be aware of all of their senses at the time of the
trauma, and their present thoughts and emotions as they express this experience.
Step 3: Processing
Invite clients to share thoughts, feelings, and insights relative to this exercise. The process
questions below can be used to help clients express more about their work.
1. What about this exercise surprised you?
2. How has the traumatic experience affected you?
3. What do you wish you had done differently?
4. Are you a victim or a survivor? If you are a victim, what would it take to be a survivor?

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Intervention: Lost and Found

Objectives:
Clients will identify losses related to trauma they have experienced. Clients will identify
positive areas of growth or strength they may have developed due to the trauma. Clients will recognize
personal progress in coping.
Procedure:
Step 1: Group Discussion
Discuss the losses that clients have experienced due to trauma. They may include a sense of
safety and security, meaning and purpose in life, physical health or body integrity, the ability to relate
effectively with others, self-esteem or identity, or someone or something they love. Discuss emotions
related to trauma such as shock denial, anger, vulnerability and grief. Discuss the positive things that
may have occurred such as individual growth and coping, compassion for others that may have
developed because of the trauma experienced.
Step 2: Experiential Exercise
Clients will illustrate the losses they have experienced due to trauma and identify any positive
changes related to it.
Step 3: Processing
Invite clients to share thoughts, feelings, and insights relative to this exercise. The process
questions below can be used to help clients express more about their work.
1. Are the losses permanent or are there ways that they can be recovered?
2. How are the losses effecting current decisions and behaviors?
3. If you have found positives, how can they be used to deal with the losses?

112

4. How can this experience help you to gain a sense of personal control in your life?

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APPENDIX E: DEMOGRAPHIC QUESTIONNAIRE

114

1. Confidential I.D. ___________

2. Age__________
3. Race or Ethnicity

White (not of Hispanic Origin)

Black or African American (not of Hispanic Origin)
American Indian & Alaska Native
Asian
Native Hawaiian & Pacific Islander
Hispanic or Latino of any race
Some other race

4. Education completed: (check one)

Less than High School Graduation

High School Graduation or GED
One Year Post-High School Education
Vocational degree
Two years of college or Associates Degree
Four years of College or Bachelors degree
Post-Bachelors work
Graduate degree

5. Did you experience learning and behavioral problems while in school?

no
yes
6.

Please select any exceptional learning or academic educational services you were qualified for
in school:
Gifted & Talented
SLD (Specific learning disabilities)
Mentally Handicapped
Emotionally Handicapped (SED, EH or EBH)
Other Health Impaired (OHI, OH, TBI, DHH)

7. Relationship Status
Never married
Married
Divorced/Separated
Living together
8. If you are or have been married, how many times have you been married? ________
9. How many natural or adopted children do you have? (whether in your custody or not) _______
10. Of your children, how many are: (check all that apply)
Under 18 years old How many?______

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 In your custody
How many?______
In the custody of a family member How many?______
In State custody
How many?______
11. Did you grow up in a home with:
Both natural parents present
Single Mother
Single Father
Remarried parents (one parent and a step-parent)
Other (explain)__________________________
12. Do you have any medical problems?
no.
yes If yes, please describe them. _________________________

13. Have you ever been told by a doctor that you have a mental health diagnosis?
no
yes If yes, please describe your diagnosis. _________________________

14. Have you ever been hospitalized for mental health reasons?
no
yes
15. What are the charges for your current arrest?

16. How many times have you been incarcerated?___________

17. Are other members of your immediate family currently incarcerated or have been incarcerated
in the past?
no
yes

18. Do you have a history of (check all that apply)

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 sexual abuse
physical abuse
domestic violence
none of the above

19. How old were you when you experienced the abuse?
Under ten years old
Between 10 and 20 years old
Between 21 and 30 years old
Older than 31

20. Before your arrest, were you:

employed
seeking employment
unemployed, not seeking employment

21. Were you under the influence of drugs and/or alcohol at the time of your arrest?
no
yes

22. Describe your drug and alcohol use prior to your arrest: (please check all that apply)
If you ever used the substance mark yes and if you used it regularly check the box provided.
Alcohol

yes

regularly

Marijuana or hashish

yes

regularly

Cocaine or crack

yes

regularly

Heroin/opiates

yes

regularly

Depressants

yes

regularly

Stimulants

yes

regularly

Hallucinogens

yes

regularly

Inhalants

yes

regularly

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APPENDIX F: POST STUDY EVALUATION

118

Confidential I.D. ________

Please complete each of the questions below. If you need more room, have suggestions or additional
information you would like to share, please do so on the back of this form. All information will be kept
confidential.
Your responses may assist in improving current programs and designing future programs for women who
are incarcerated.

1. How was this experience enjoyable for you?

Please explain how this experience has been a positive experience for you.

2. What was there about this experience that you did not like?

3. Would you recommend this group to others? Why or why not?

4. Did this experience help you to address unpleasant experiences from your past? Please
explain.

5. Additional comments and suggestions

119

REFERENCES
Abrams, K. A., Teplin, L. A., & McClelland, G. M. (2003). Comorbidity of severe psychiatric
disorders and substance use disorders among women in jail. American Journal of
Psychiatry, 160, 1007-1010.
Alemagno, S. A. (2001). Women in jail: Is substance abuse treatment enough? American
Journal of Public Health, 91, 796-800.
American Art Therapy Association. (2005). Information and membership. Munelein, IL: Author.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders, (4th ed.). Washington, DC: Author.
Becker, J., Skinner, L., Abel, G., & Treacy, E. (1982). Incidence and types of sexual
dysfunctions in rape and incest victims. Journal of Sex & Marital Therapy, 8, 65-74.
Birch, M.A. (1997). The health benefits of art therapy following traumatic life
experiences. Ph.D. dissertation, California School of Professional Psychology Berkeley/Alameda, United States -- California. Retrieved July 30, 2007, from ProQuest
Digital Dissertation database. (Publication No. AAT 9817060).
Blitz, C., Wolff, N., & Paap, K. (2006). Availability of behavioral health treatment for
women in prison. Psychiatric Services, 57, 356-360.
Boothroyd, G. W. (1995). Goin Home: A therapeutic and spiritual guide toward eliminating
self-defeating behaviors. Delton, Michigan: Greenwood Associates.
Bouffard, J. A., & Taxman, F. S. (2000). Client gender and the implementation of jail-based
therapeutic community programs. Journal of Drug Issues, 30, 881- 900.

120

Bradley, R. & Davino, K. (2007). Interpersonal violence, recovery, and resilience in incarcerated
women. Journal of Aggression, Maltreatment & Trauma, 14, 123-147.
Bradshaw, J. (1988). Healing the shame that binds you. Dearfield Beach: Health
Communications Inc.
Bradley, R. G., & Follingstad, D. R. (2003). Group therapy for incarcerated women who
experienced interpersonal violence: A pilot study. Journal of Traumatic Stress, 16,
337-340.
Briere, J. (n.d.). Trauma Symptom Inventory. Retrieved July 20, 2007, from Mental
Measurements Yearbook database.
Byrne, M. W. (2005). Conducting research as a visiting scientist in a womens prison. Journal of
Professional Nursing, 21, 223-230.
Carlson, T.D. (1997). Using art in narrative therapy: Enhancing therapeutic possibilities. The
American Journal of Family Therapy, 25, 271-283.
Carson, D.K., & Becker, K. W. (2004). When lightning strikes: Reexamining creativity in
psychotherapy. Journal of Counseling & Development, 82, 111-115.
Cohen, B. M., Barnes, M, & Rankin, A. B. (1995). Managing traumatic stress through art
drawing from the center. Baltimore: The Sidran Press.
Collie, K., Backos, A., Malchiodi, C., & Spiegel, D. (2006). Art therapy for combat-related
PTSD: Recommendations for research and practice. Art Therapy: Journal of the
American Art Therapy Association, 23,157-164.
Covington, S. (1999). Helping women recover: a program for treating addiction: facilitator's
guide. San Francisco: Jossey-Bass.

121

Covington, S. S., & Bloom, B. E. (2007). Gender responsive treatment and services in
correctional settings. Women & Therapy, 29, 9-33.
Covington, S. S. (2007). Women and the criminal justice system. Womens Health Issues, 17,
180-182.
Cronin, P. (1994). Ways of working: Art therapy with women in Holloway prison. In M.
Liebmann (Ed.), Art therapy with offenders (pp. 102-120). London: Jessica Kingsley
Ltd.
Eisdell, N. (2005). A conversational model of art therapy. Psychology and Psychotherapy:
Theory, Research and Practice, 78, 1-19.
Fernandez, E. (n.d.). [Review of The Trauma Symptom Inventory]. Retrieved July 20, 2007, from
Mental Measurements Yearbook database.
Ferszt, G. G., Hayes, P. M., DeFedele, S., & Horn, L. (2004). Art therapy with incarcerated
women who have experienced the death of a loved one. Journal of the American Art
Therapy Association, 21, 191-199.
Field, A. (2005). Discovering statistics using SPSS (2nd ed.). Thousand Oaks: Sage.
Fillip, C. A. (1994). In focus: The value inherent in a single session of art therapy. American
Journal of Art Therapy, 33, 2-5.
Finn, C. A., & Pearson, L. B. (2003). Helping students cope with loss: Incorporating art into
group counseling. Journal for Specialists in Group Work, 28, 155-165.
Frattaroli, J. (2006). Experimental disclosure and its moderators: A meta-analysis. Psychological
Bulletin, 132, 823-865.

122

Frost, N. A., Greene, J., & Pranis, K. (2006). HARD HIT: The Growth in the Imprisonment of
Women, 1977-2004 Printed by the Institute on Women & Criminal Justice The
Punitiveness Report. Copyright 2006 by Womens Prison Association. Retrieved on line
October 15, 2007 from http://66.29.139.159/pdf/HARD HIT Full Report.pdf
Gerity, L. A. (1997). The reparative qualities of art therapy: Dissociative identity disorder and
body image development. D.A. dissertation, New York University, United States -- New
York. Retrieved October 15, 2007, from Dissertations & Theses: Full Text database.
(Publication No. AAT 9718708).
Gibbons, J. A. (1997). Struggle and catharsis: Art in womens prisons. Journal of Arts
Management, Law and Society, 27, 72-80.
Giller, E. (1999). What is psychological trauma? Retrieved June 29, 2007, from
http://www.sidran.org/sub.cfm?contentID=88&sectionid=4
Gladding, S. T., (1992). The expressive arts in counseling (ERIC Digest ED350528). Retrieved
October 15, 2007, from http://www.eric.ed.gov/
Gladding, S. T. (2005). Counseling as an art: The creative arts in counseling. Alexandria:
American Counseling Association.
Grella, C. E., & Greenwell, L. (2007). Treatment needs and completion of community-based
aftercare among substance-abusing women offenders. Womens Health Issues, 17, 244255.
Gross, J., & Haynes, H. (1998). Drawing facilitates childrens verbal reports of emotion laden
events. Journal of Experimental Psychology, 4, 163-179.

123

Gussak, D. (2004). Art therapy with prison inmates: a pilot study. The Arts in psychotherapy, 31,
245-259.
Gussak, D. (2006). Effects of art therapy with prison inmates: A follow-up study. The arts in
psychotherapy, 33, 188-198.
Gussak, D. (2007). The effectiveness of art therapy in reducing depression in prison populations.
International Journal of Offender Therapy and Comparative Criminology, 52, 444-460.
Haesseler, M. P. (1992). Ethical considerations for the group therapist. American Journal of Art
Therapy,31, 2-10.
Hall, E., Baldwin, D., & Prendergast, M. (2001). Women on parole: Barriers to
success after substance abuse treatment. Human Organization, 60, 225-233.
Hanes, M. J. (2001). Retrospective review in art therapy; creating a visual record of the
therapeutic process. American Journal of Art Therapy, 40, 149-160.
Hanney, L., & Kozlowska, K. (2002). Healing traumatized children: Creating illustrated
storybooks in family therapy. Family Process 41, 37-65.
Hanson, W. E. (n.d.). [Review of the OQ-45.2 (Outcome Questionnaire)]. Retrieved July 20,
2007, from Mental Measurements Yearbook database.
Harrington, C. L. (1997). Time to piddle: death row incarceration, craftwork, and the
meaning of time. (Art and Catharsis). Journal of Arts Management, Law and Society
27, 51-61.
Haywood, T. W., Kravitz, H. M., Boldman, L. B., & Freeman, A. (2000). Characteristics of
women in jail and treatment orientations: A review. Behavioral Modification 24, 307324.

124

Henriques, Z. (2002). Diversion programming: Integrating treatment with criminal justice

sanctions for women with co-occurring disorders. Retrieved September 15, 2006, from
http://gainscenter.samhsa.gov/html/resources/publications.asp#jaildiv
James, D. J., & Glaze, L. E. (2006). Mental health problems of prison and jail inmates.
Bureau of Justice Statistics Special Report (NCJ 213600) Retrieved September 5, 2006,
from http://gb1.ojp.usdoj.gov/search
Kahn, B.B., Villanova, U. (1999). Art therapy with adolescents: making it work for school
counselors. Professional School Counseling, 2, 291-298.
Karban, B., & West, A. (1994). Working as an art therapist in a Regional Secure Unit. Art
therapy with offenders (pp. 135-164). London England: Jessica Kingsley Publishers.
Kelly, K., & Empson, G. (1999). Advocating for women in the criminal justice and addiction
treatment systems in Lewis, J., Bradley, L. (Eds.) Advocacy in Counseling: Counselors,
Clients, & Community. pp. 149-153. (ERIC Document Reproduction Service No.
ED435904) Retrieved October 15, 2007, from ERIC database.
King, L. A. (2002) Gain without pain? Expressive writing and self-regulation. In S. J. Lepore &
J. M. Smyth (Eds.) The writing cure how expressive writing promotes health and
emotional well-being (pp 119-134). Washington, D. C.: American Psychological
Association.
Kwiatrowska, H. Y. (2001). Family art therapy: Experiments with a new technique. American
Journal of Art Therapy, 40, 27-39.

125

Lambert, M., Morton, J., Hatfield, D., Harmon, C., Hamilton, S., Reid, R., et al. (n.d.). OQ-45.2
(Outcome Questionnaire). Retrieved July 20, 2007, from Mental Measurements
Yearbook database.
Lambert, M. J., Morton, J. J., Hatfield, D., Harmon, C., Hamilton, S., Reid, et al. (2004).
Administration and Scoring Manual for the OQ-45.2 Outcome Measures. American
Professional Credentialing Services L.L.C.
Lepore, S. J., & Smyth, J. M. (Eds.). (2002). The writing cure: How expressive writing promotes
health and emotional well-being. Washington, D.C.: American Psychological
Association.
Liebmann, M. (Ed). (1994). Art Therapy with Offenders. London, Jessica Kingsley Publishers.
Mageehon, A. (2003). Incarcerated womens educational experiences. The Journal of
Correctional Education, 54, 191-199.
Malchiodi, C. A. (1998). The art therapy sourcebook. Los Angeles: Lowell House.
Malchiodi, C. A. (2001). Using drawings as intervention with traumatized children. Trauma and Loss
Research and Interventions, 1, 21-27.
Malchiodi, C. (Ed.). (2003). Handbook of art therapy. New York, NY: Guilford.
Mcgeehon, A. (2003). Incarcerated womens educational experiences. The journal of
correctional education, 54, 191-199.
Merker, B. M. (n.d.). [Review of the OQ-45.2 (Outcome Questionnaire)]. Retrieved July 20,
2007, from Mental Measurements Yearbook database.
Merriam, B. (1998). To find a voice: Art therapy in a womens prison. Women & Therapy,
21, 157-171.

126

Messina, N., & Grella, C. (2006). Childhood Trauma and Women's Health Outcomes in a
California Prison Population. American Journal of Public Health, 96, 1842-1848.
Norton-Hawk, M. (2001). The counterproductivity of incarcerating female street
prostitutes. Deviant Behavior, 22(5), 403-417.
Parsons, M. L., & Warner-Robbins, C. (2002). Factors that support womens successful
transition to the community following jail/prison. Health Care and Women International,
23, 6-18.
Pennebaker, J. D. (1990). Opening up the healing power of confiding in others. New York:
William Morrow and Company, Inc.
Pennebaker, J. D. (2002). Writing about emotional events: From past to future. In S. J. Lepore &
J. M. Smyth (Eds.). The writing cure how expressive writing promotes health and
emotional well-being (pp281-291). Washington, D.C.: American Psychological
Association.
Pfeiffer, S. I. (n.d.). [Review of the OQ-45.2 (Outcome Questionnaire)]. Retrieved July 20,
2007, from Mental Measurements Yearbook database.
Pifalo, T. (2006). Art therapy with sexually abused children and adolescents: Extended research
study. Journal of the American Art Therapy Association, 23, 181-185.
Pomeroy, E. C., Kiam, R., & Abel, E. (1998). Meeting the mental health needs of incarcerated
women. Health & Social Work, 23, 71-76.
Pressman, M. J. (2005). Groups after September 11: Beyond the small group. International
Journal of Group Psychotherapy, 55, 465-470.

127

Radosh, P. F. (2002). Reflections on womens crime and mothers in prison: A peacemaking

approach. Crime & Delinquency, 48, 300-315.
Richards, J. M., Beal, W. E., Seagal, J. D., & Pennebaker, J. W. (2000). Effects of disclosure of
traumatic events on illness behavior among psychiatric prison inmates. Journal of
Abnormal Psychology, 109, 156-160.
Riley, S. (2001). Art therapy with adolescents. The western journal of Medicine, 175, 54-60.
Rothchild, B. (2000). The body remembers: The psychophysiology of trauma and trauma
treatment. New York: Norton.
Rubin, J.A. (1968). Art therapy an introduction. Philadelphia: Brunner/Mazel.
Rubin, J. A. (Ed.). (2001). Approaches to art therapy theory and technique (2nd ed.). New York:
Brunner-Routledge.
Samuels, M. (1994). Art as a healing force: a new movement uses art to heal the sick.
Performing Arts and Entertainment in Canada, 29, 37-39.
Singer, M. I., Bussey, J., Song, L., & Lunghofer, L. (1995). The psychosocial issues of women
serving time in jail. Social Work, 40, 103-114.
Stanford, A. F. (2005). Where love flies free: Women, home, and writing in the cook county jail.
Journal of Prevention & in the Community, 30, 49-56.
Staton, M., Leukefeld, C., & Logan, T. (2001). Health services utilization and victimization
among incarcerated female substance users. Substance Use & Misuse, 36, 701-716.
Tosone, C., Gelman, C. R., & McVeigh, L. (2005). Through their own eyes: A media-based
group approach to adolescent trauma. International Journal of Group Psychotherapy,
55, 415-432.

128

Ulman, E., (1992). Therapy is not enough: The contribution of art to general hospital psychiatry.
American Journal of Art Therapy, 30, 89-100.
Valentine, P. V., & Smith, E. S. (2001). Evaluating traumatic incident reduction therapy with
female inmates: A randomized controlled clinical trial. Research on Social Work
Practice, 11, 40-52.
Waller, D. (2003). Group art therapy: An interactive approach. In C. Malchiodi (Ed.), Handbook
of Art Therapy (pp.313-324). New York: Guilford Press.
Wellisch, J., Anglin, M. D., & Pendergast, M. L. (1993). Numbers and characteristics of drugusing women in the criminal justice system: Implications for treatment. Journal of
Drug Issues, 23, 7-30.
Wells, D., & Bright, L. (2005). Drug treatment and reentry for incarcerated women,
Corrections Today, 67, 98-111.
Whitfield, C. L. (1989). Healing the child within: Discovery and recover for adult children of
dysfunctional families. Deerfield Beach, Florida: Health Communications, Inc.
Wilson, M. (2000). Creativity and shame reduction in sex addiction treatment. Sexual Addiction &
Compulsivity, 7, 239-248.
Wilson, M. (1998). Portrait of a Sex Addict. Sexual Addiction and Compulsivity, 5, 231-250.
Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy. NY: Basic Books.
Young, M. E., & Bemak, F. (1996). Emotional arousal and expression in mental health
counseling. Journal of Mental Health Counseling, 18, 316-332.

129

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